Form Sf 424 (R&r) - Application For Federal Assistance Page 2
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2SF 424 (R&R)
Page 2
APPLICATION FOR FEDERAL ASSISTANCE
14. PROJECT DIRECTOR/PRINCIPAL INVESTIGATOR CONTACT INFORMATION
Prefix:
First Name:
Middle Name:
Last Name:
Suffix:
Position/Title:
Organization Name:
Department:
Division:
Street1:
Street2:
City:
County / Parish:
State:
Province:
Country:
ZIP / Postal Code:
USA: UNITED STATES
Phone Number:
Fax Number:
Email:
15. ESTIMATED PROJECT FUNDING
16. IS APPLICATION SUBJECT TO REVIEW BY STATE EXECUTIVE ORDER
12372 PROCESS?
THIS PREAPPLICATION/APPLICATION WAS MADE
a. Total Federal Funds Requested
AVAILABLE TO THE STATE EXECUTIVE ORDER 12372
PROCESS FOR REVIEW ON:
b. Total Non-Federal Funds
DATE:
c. Total Federal & Non-Federal Funds
PROGRAM IS NOT COVERED BY E.O. 12372; OR
d. Estimated Program Income
PROGRAM HAS NOT BEEN SELECTED BY STATE FOR
REVIEW
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 (Disclosure of Lobbying Activities) or other Explanatory Documentation
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19. Authorized Representative
Prefix:
First Name:
Middle Name:
Suffix:
Last Name:
Position/Title:
Organization:
Department:
Division:
Street1:
Street2:
City:
County / Parish:
Province:
State:
Country:
ZIP / Postal Code:
USA: UNITED STATES
Phone Number:
Fax Number:
Email:
Date Signed
Signature of Authorized Representative
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20. Pre-application
21. Cover Letter Attachment
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