Application For Federal Assistance Sf-424 Form - 2012 Page 3
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4OMB Number: 4040-0004
Expiration Date: 01/31/2012
Application for Federal Assistance SF-424
Version 02
16. Congressional Districts Of:
*a. Applicant
*b. Program/Project:
Attach an additional list of Program/Project Congressional Districts if needed.
17. Proposed Project:
*a. Start Date:
*b. End Date:
18. Estimated Funding ($):
*a. Federal
*b. Applicant
*c. State
*d. Local
*e. Other
*f. Program Income
*g. TOTAL
$0.00
*19. Is Application Subject to Review By State Under Executive Order 12372 Process?
a. This application was made available to the State under the Executive Order 12372 Process for review on
b. Program is subject to E.O. 12372 but has not been selected by the State for review.
c. Program is not covered by E.O. 12372
*20. Is the Applicant Delinquent On Any Federal Debt? (If “Yes”, provide explanation.)
Yes
No
21. *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 218, 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.
Authorized Representative:
Prefix:
*First Name:
Middle Name:
*Last Name:
Suffix:
*Title:
*Telephone Number:
Fax Number:
*Email:
*Signature of Authorized Representative:
Date Signed:
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