Application for Federal Assistance SF 424 - Individual

1 - 4. General Information:

1. Name of Federal Agency:

2. Catalog of Federal Domestic Assistance Number:

CFDA Title:

3. Date Received:

4. Funding Opportunity Number:

Funding Opportunity Title:

5. Applicant Information:

a. Name and Contact Information

Name:

Prefix:

Other (Specify):

First Name:

Middle Name:

Last Name:

Suffix:

Other (Specify):

Telephone Number (Daytime):

Telephone Number (Evening):

Fax Number:

Email:

Street Address:

b. Address

Street1:

Street2:

City:

County / Parish:

State:

Province:

Country:

ZIP / Postal Code:

c. Citizenship Status:

U.S. Citizenship:

Yes

If No:

If permanent resident of U.S., enter the Alien Registration Number:

If foreign national, enter country of citizenship:

If foreign national, enter start date of most recent residency in U.S.:

d. Congressional District of Applicant:

Congressional District of Applicant:

6. Project Information:

a. Project Title:

b. Project Description:

c. Proposed Project:

Start Date:

End Date:

7. Application Certification:

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.

Signature:

Date Signed:

8. Burden Statement

SF-424 Individual Form (4040-0005)

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 4040-0005. The time required to complete this information collection is estimated to average 27 minutes per response, 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
NEA	1,150	10/60	192
NEH	2,593	30/60	1,297
USDA	4,069	30/60	2,035
HHS	600	30/60	300

Total	8,412		3,824

3,824 total hours x 60 minutes = 229,440 total minutes
229,440 / 8,412 total reponses = 27 minutes per response.