OMB Number: 4040-0001 Expiration Date: 06/30/2011

APPLICATION FOR FEDERAL ASSISTANCE SF 424 (R&R)

3. DATE RECEIVED BY STATE

State Application Identifier

1.* TYPE OF SUBMISSION

4.a. Federal Identifier

Y: Yes

N: No

Pre-application

Y: Yes

N: No

Application

Y: Yes

N: No

Changed/Corrected Application

b. Agency Routing Number

2. DATE SUBMITTED

Application Identifier

5. APPLICANT INFORMATION

* Organizational DUNS:

* Legal Name:

Person to be contacted on matters involving this application

6. * EMPLOYER IDENTIFICATION NUMBER (EIN) or (TIN) :

7. * TYPE OF APPLICANT

Other (Specify):

Small Business Organization Type

Women Owned

Socially and Economically Disadvantaged

8. * TYPE OF APPLICATION:

Y: Yes

N: No

New

Y: Yes

N: No

Resubmission

Y: Yes

N: No

Renewal

Y: Yes

N: No

Continuation

Y: Yes

N: No

Revision

If Revision, mark appropriate box(es).

Y: Yes

N: No

A. Increase Award

Y: Yes

N: No

B. Decrease Award

Y: Yes

N: No

C. Increase Duration

Y: Yes

N: No

D. Decrease Duration

Y: Yes

N: No

E. Other (specify) :

* Is this application being submitted to other agencies?

Y: Yes

N: No

Yes

Y: Yes

N: No

What other Agencies?

9. * NAME OF FEDERAL AGENCY:

10. CATALOG OF FEDERAL DOMESTIC ASSISTANCE NUMBER:

TITLE:

11. * DESCRIPTIVE TITLE OF APPLICANT'S PROJECT:

12. PROPOSED PROJECT:

* Start Date

* Ending Date

13. CONGRESSIONAL DISTRICTS OF:

a. * Applicant

14. PROJECT DIRECTOR/PRINCIPAL INVESTIGATOR CONTACT INFORMATION

Position/Title:

* Organization Name:

SF 424 (R&R) APPLICATION FOR FEDERAL ASSISTANCE

Page 2

15. ESTIMATED PROJECT FUNDING

16.

* IS APPLICATION SUBJECT TO REVIEW BY STATE EXECUTIVE ORDER 12372 PROCESS?

YES

THIS PREAPPLICATION/APPLICATION WAS MADE AVAILABLE TO THE STATE EXECUTIVE ORDER 12372 PROCESS FOR REVIEW ON:

DATE:

Y: Yes

N: No

PROGRAM IS NOT COVERED BY E.O. 12372; OR

Y: Yes

N: No

PROGRAM HAS NOT BEEN SELECTED BY STATE FOR REVIEW

a. * Total Federal Funds Requested

b. * Total Non-Federal Funds

c. * Total Federal & Non-Federal Funds

d. * Estimated Program Income

17.

By signing this application, I certify (1) to the statements contained in the list of certifications* and (2) that the statements herein are true, complete and accurate to the best of my knowledge. I also provide the required assurances * and agree to comply with any resulting terms if I accept an award. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties. (U.S. Code, Title 18, Section 1001)

* I agree

* The list of certifications and assurances, or an Internet site where you may obtain this list, is contained in the announcement or agency specific instructions.

18. SFLLL or other Explanatory Documentation

19. Authorized Representative

* Position/Title:

* Organization Name:

* Signature of Authorized Representative

* Date Signed

20. Pre-application File Name: Mime Type:

Department:

Division:

* Street1:

Street2:

* City:

County:

* State:

Province:

* Country:

* ZIP / Postal Code:

Prefix:

* First Name:

Middle Name:

* Last Name:

Suffix:

* Phone Number:

Fax Number:

* Email:

* Phone Number:

Fax Number:

Email:

Y: Yes ● ❍ ❍ Yes ● No ● Yes ❍ No