Standard Form 424 - Application For Federal Assistance printable pdf download

OMB Approval No. 0348-0043

APPLICATION FOR

2. DATE SUBMITTED

Applicant Identifier

FEDERAL ASSISTANCE

1. TYPE OF SUBMISSION:

3. DATE RECEIVED BY STATE

State Application Identifier

Application

Preapplication

~ Construction

4. DATE RECEIVED BY FEDERAL AGENCY

Federal Identifier

~ Non-Construction

5. APPLICANT INFORMATION

Legal Name:

Organizational Unit:

Address (give city, county, State and zip code):

Name and telephone number of the person to be contacted on matters involving

this application (give area code):

6. EMPLOYER IDENTIFICATION NUMBER (EIN):

GG-GGGGGGG

7. TYPE OF APPLICANT: (enter appropriate letter in box)

A. State

H Independent School Dist.

I State Controlled Institution of Higher Learning

B. County

C. Municipa J . Private University

8. TYPE OF APPLICATION:

K Indian Tribe

D. Township

~ New

~ Continuation

~ Revision

E. Interstate

L. Individual

F. Intermunicipal

M. Profit Organization

G G

N. Other (Specify): _____________________________

G. Special District

If Revision, enter appropriate letter(s) in box(es):

9. NAME OF FEDERAL AGENCY:

A. Increase Award

B. Decrease Award

C. Increase Duration

D. Decrease Duration

Other (specify):

______________________________________________________________

10. CATALOG OF FEDERAL DOMESTIC ASSISTANCE NUMBER:

11. DESCRIPTIVE TITLE OF APPLICANT'S PROJECT:

GG-GGG

TITLE:

12. AREAS AFFECTED BY PROJECT (cities, counties, States, etc.):

13. PROPOSED PROJECT:

14. CONGRESSIONAL DISTRICTS OF:

Start Date

Ending Date

a. Applicant

b. Project

15. ESTIMATED FUNDING:

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

a. YES. THIS PREAPPLICATION/APPLICATION WAS MADE AVAILABLE TO THE

a. Federal

.00

STATE EXECUTIVE ORDER 12372 PROCESS FOR REVIEW ON

b. Applicant

.00

DATE ______________________________________

c. State

.00

b. NO. ~ PROGRAM IS NOT COVERED BY E.O. 12372

d. Local

.00

~ OR PROGRAM HAS NOT BEEN SELECTED BY STATE FOR REVIEW

e. Other

.00

f. Program Income

.00

17. IS THE APPLICANT DELINQUENT ON ANY FEDERAL DEBT?

~ Yes

~ No

If "Yes," attach an explanation.

g. TOTAL

.00

18. TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL DATA IN THIS APPLICATION/PREAPPLICATION ARE TRUE AND CORRECT. THE DOCUMENT HAS BEEN DULY

AUTHORIZED BY THE GOVERNING BODY OF THE APPLICANT AND THE APPLICANT WILL COMPLY WITH THE ATTACHED ASSURANCES IF THE ASSISTANCE IS AWARDED.

a. Typed Name of Authorized Representative

b. Title

c. Telephone number

d. Signature of Authorized Representative

e. Date Signed

Previous Editions Not Usable

Standard Form 424 (REV 4-88)

Prescribed by OMB Circular A-102

Standard Form 424 - Application For Federal Assistance

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