Application for Federal Assistance – SF 424 (R&R)

Select Type of Submission:

Pre-application

Application

Changed/Corrected Application

Date Submitted:

Applicant Identifier:

Date Received by State:

State Application Identifier:

a. Federal Identifier:

b. Agency Routing Identifier:

c. Previous Grants.gov Tracking ID:

Organizational DUNS:

Legal Name:

Department:

Division:

Street Address:

Street1:

Street2:

City:

County / Parish:

State:

Province:

Country:

ZIP / Postal Code:

Contact Name:

Prefix:

Other (Specify):

First Name:

Middle Name:

Last Name:

Suffix:

Other (Specify):

Position/Title:

Street Address:

Street1:

Street2:

City:

County / Parish:

State:

Province:

Country:

ZIP / Postal Code:

Phone Number:

Fax Number:

Email:

EIN or TIN:

Type of Applicant:

Other (Specify):

Small Business Organization Type:

Women Owned

Socially and Economically Disadvantaged

Type of Application:

New

Resubmission

Renewal

Continuation

Revision

If Revision, Mark Appropriate Box(es):

A. Increase Award

B. Decrease Award

C. Increase Duration

D. Decrease Duration

E. Other (Specify):

Is this application being submitted to other agencies?:

Yes

What other Agencies?:

Name of Federal Agency:

CFDA Number:

CFDA Title:

Start Date:

End Date:

Congressional District Code:

Name:

Prefix:

Other (Specify):

First Name:

Middle Name:

Last Name:

Suffix:

Other (Specify):

Position/Title:

Organization Name:

Department:

Division:

Street Address:

Street1:

Street2:

City:

County / Parish:

State:

Province:

Country:

ZIP / Postal Code:

Phone Number:

Fax Number:

Email:

a. Total Federal Funds Requested:

b. Total Non-Federal Funds:

c. Total Federal & Non-Federal Funds:

d. Estimated Program Income:

a. YES:

This Pre-application/Application was made available to the State Executive Order 12372 Process for review on:

Date:

b. NO:

Program is not covered by E.O. 12372; OR

Program has not been selected by State for review

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.

Attachment:

Name:

Prefix:

Other (Specify):

First Name:

Middle Name:

Last Name:

Suffix:

Other (Specify):

Position/Title:

Organization Name:

Department:

Division:

Street Address:

Street1:

Street2:

City:

County / Parish:

State:

Province:

Country:

ZIP / Postal Code:

Phone Number:

Fax Number:

Email:

Signature of Authorized Representative:

Date Signed:

Attachment:

Attachment

22. Burden Statement

SF-424 Research and Related Form (4040-0001)

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 4040-0001. The time required to complete this information collection is estimated to average 58 hours per response (depending on the combination of 4040-0001 components that are used by the agency), including the time to review instructions, search existing data resources, gather the data needed and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.

Agency	Total Responses	Average Burden per response in Hours	Total Burden Hours
DOC	2,300	25/60	958
DOE	15,150	1.5	22,725
ED	1,200	40	48,000
HHS	92,250	58.73	5,418,000
DOD	12,500	1.07	13,345
NASA	10,000	1.5	15,000
USDA	6,000	1.25	7,500
NSF	40,000	120	4,800,000
DHS	350	120	42,000

Total	179,750		10,367,528

10,367,528 / 179,750 total responses = 58 hours