TEGL20-01C7a1.pdf

ETA Advisory File Text

Version 02 OMB Number 4040-0004 Expiration Date 0 1 31 2009 1. Type of Submission Preapplication Application Changed Corrected Application 2. Type of Application New Continuation Revision Completed by Grants.gov upon submission. 3. Date Received 4. Applicant Identifier 5a. Federal Entity Identifier 5b. Federal Award Identifier 6. Date Received by State 7. State Application Identifier a. Legal Name b. Employer Taxpayer Identification Number EIN TIN c. Organizational DUNS Street1 Street2 City County State Province Country USA UNITED STATES Zip Postal Code Department Name Division Name Prefix First Name Middle Name Last Name Suffix Title Organizational Affiliation Telephone Number Fax Number Email If Revision select appropriate letter s State Use Only 8. APPLICANT INFORMATION d. Address e. Organizational Unit f. Name and contact information of person to be contacted on matters involving this application Application for Federal Assistance SF-424 Other Specify 9. Type of Applicant 1 Select Applicant Type Type of Applicant 2 Select Applicant Type Type of Applicant 3 Select Applicant Type Other specify 10. Name of Federal Agency NGMS Agency 11. Catalog of Federal Domestic Assistance Number CFDA Title 12. Funding Opportunity Number MBL-SF424FAMILY-ALLFORMS Title MBL-SF424Family-AllForms 13. Competition Identification Number Title 14. Areas Affected by Project Cities Counties States etc. 15. Descriptive Title of Applicant s Project Attach supporting documents as specified in agency instructions. Add Attachments Delete Attachments View Attachments Version 02 OMB Number 4040-0004 Expiration Date 0 1 31 2009 Application for Federal Assistance SF-424 a. Federal b. Applicant c. State d. Local e. Other f. Program Income g. TOTAL 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 Prefix First Name Middle Name Last Name Suffix Title Telephone Number Email Fax Number Completed by Grants.gov upon submission. Signature of Authorized Representative Completed by Grants.gov upon submission. Date Signed 18. Estimated Funding 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 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 Authorized for Local ReproductionStandard Form 424 Revised 10 2005 Prescribed by OMB Circular A-102OMB Number 4040-0004 Expiration Date 0 1 31 2009 Explanation I AGREE Application for Federal Assistance SF-424 a. Applicant Attach an additional list of Program Project Congressional Districts if needed. b. Program Project Add Attachment Delete Attachment View Attachment a. Start Date b. End Date 16. Congressional Districts Of 17. Proposed Project Version 02 Version 02 OMB Number 4040-0004 Expiration Date 0 1 31 2009 The following field should contain an explanation if the Applicant organization is delinquent on any Federal Debt. Maximum number of characters that can be entered is 4 000. Try and avoid extra spaces and carriage returns to maximize the availability of space. Application for Federal Assistance SF-424 Applicant Federal Debt Delinquency Explanation INSTRUCTIONS FOR THE SF-424 Public reporting burden for this collection of information is estimated to average 60 minutes per response including time for reviewing instructions searching existing data sources gathering and maintaining the data needed and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information including suggestions for reducing this burden to the Office of Management and Budget Paperwork Reduction Project 0348-0043 Washington DC 20503. PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET. SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY. This is a standard form including the continuation sheet required for use as a cover sheet for submission of preapplications and applications and related information under discretionary programs. Some of the items are required and some are optional at the discretion of the applicant or the Federal agency agency . Required items are identified with an asterisk on the form and are specified in the instructions below. In addition to the instructions provided below applicants must consult agency instructions to determine specific requirements. Item Entry Item Entry 10. Name Of Federal Agency Required Enter the name of the Federal agency from which assistance is being requested with this application. 1. Type of Submission Required Select one type of submission in accordance with agency instructions. Preapplication Application Changed Corrected Application If requested by the agency check if this submission is to change or correct a previously submitted application. Unless requested by the agency applicants may not use this to submit changes after the closing date. 11. Catalog Of Federal Domestic Assistance Number Title Enter the Catalog of Federal Domestic Assistance number and title of the program under which assistance is requested as found in the program announcement if applicable. 12. Funding Opportunity Number Title Required Enter the Funding Opportunity Number and title of the opportunity under which assistance is requested as found in the program announcement. 13. Competition Identification Number Title Enter the Competition Identification Number and title of the competition under which assistance is requested if applicable. 2. Type of Application Required Select one type of application in accordance with agency instructions. New An application that is being submitted to an agency for the first time. Continuation - An extension for an additional funding budget period for a project with a projected completion date. This can include renewals. Revision - Any change in the Federal Government s financial obligation or contingent liability from an existing obligation. If a revision enter the appropriate letter s . More than one may be selected. If Other is selected please specify in text box provided. A. Increase Award B. Decrease Award C. Increase Duration D. Decrease Duration E. Other specify 14. Areas Affected By Project List the areas or entities using the categories e.g. cities counties states etc. specified in agency instructions. Use the continuation sheet to enter additional areas if needed. 3. Date Received Leave this field blank. This date will be assigned by the Federal agency. 4. Applicant Identifier Enter the entity identifier assigned buy the Federal agency if any or the applicant s control number if applicable. 15. Descriptive Title of Applicant s Project Required Enter a brief descriptive title of the project. If appropriate attach a map showing project location e.g. construction or real property projects . For preapplications attach a summary description of the project. 5a. Federal Entity Identifier Enter the number assigned to your organization by the Federal Agency if any. 5b. Federal Award Identifier For new applications leave blank. For a continuation or revision to an existing award enter the previously assigned Federal award identifier number. If a changed corrected application enter the Federal Identifier in accordance with agency instructions. 6. Date Received by State Leave this field blank. This date will be assigned by the State if applicable. 7. State Application Identifier Leave this field blank. This identifier will be assigned by the State if applicable. 8. Applicant Information Enter the following in accordance with agency instructions 16. Congressional Districts Of Required 16a. Enter the applicant s Congressional District and 16b. Enter all District s affected by the program or project. Enter in the format 2 characters State Abbreviation 3 characters District Number e.g. CA-005 for California 5th district CA- 012 for California 12th district NC-103 for North Carolina s 103rd district. If all congressional districts in a state are affected enter all for the district number e.g. MD-all for all congressional districts in Maryland. If nationwide i.e. all districts within all states are affected enter US-all. If the program project is outside the US enter 00-000. a. Legal Name Required Enter the legal name of applicant that will undertake the assistance activity. This is ththat the organization has registered with the Central Contractor Registry. Information on registering with CCR may be obtained by visiting the Grants.gov website. 17. Proposed Project Start and End Dates Required Enter the proposed start date and end date of the project. b. Employer Taxpayer Number EIN TIN Required Enter the Employer or Taxpayer Identification Number EIN or TIN as assigned by the Internal Revenue Service. If your organization is not in the US enter 44-4444444. 18. Estimated Funding Required Enter the amount requested or to be contributed during the first funding budget period by each contributor. Value of in-kind contributions should be included on appropriate lines as applicable. If the action will result in a dollar change to an existing award indicate only the amount of the change. For decreases enclose the amounts in parentheses. c. Organizational DUNS Required Enter the organization s DUNS or DUNS 4 number received from Dun and Bradstreet. Information on obtaining a DUNS number may be obtained by visiting the Grants.gov website. 19. Is Application Subject to Review by State Under Executive Order 12372 Process Applicants should contact the State Single Point of Contact SPOC for Federal Executive Order 12372 to determine whether the application is subject to the State intergovernmental review process. Select the appropriate box. If a. is selected enter the date the application was submitted to the State. d. Address Enter the complete address as follows Street address Line 1 required City Required County State Required if country is US Province Country Required Zip Postal Code Required if country is US . 20. Is the Applicant Delinquent on any Federal Debt Required Select the appropriate box. This questio n applies to the applicant organization not the person who signs as the authorized representative. Categories of debt include delinquent audit disallowances loans and taxes. If yes include an explanation on the continuation sheet. e. Organizational Unit Enter the name of the primary organizational unit and department or division if applicable that will undertake the assistance activity if applicable. f. Name and contact information of person to be contacted on matters involving this applicat required organizational affiliation if affiliated with an organization other on Enter the name First and last name than the applicant organization telephone number Required fax number and email address Required of the person to contact on matters related to this application. 21. Authorized Representative Required To be signed and dated by the authorized representative of the applicant organization. Enter the name First and last name required title Required telephone number Required fax number and email address Required of the person authorized to sign for the applicant. A copy of the governing body s authorization for you to sign this application as the official representative must be on file in the applicant s office. Certain Federal agencies may require that this authorization be submitted as part of the application. Type of Applicant Required Select up to three applicant type s in accordance with agency instructions. 9. A. State Government B. County Government C. City or Township Government D. Special District Government E. Regional Organization F. U.S. Territory or Possession G. Independent School District H. Public State Controlled Institution of Higher Education I. Indian Native American Tribal Government Federally Recognized J. Indian Native American Tribal Government Other than Federally Recognized K. Indian Native American Tribally Designated Organization L. Public Indian Housing Authority M. Nonprofit N. Nonprofit O. Private Institution of Higher Education P. Individual Q. For-Profit Organization Other than Small Business R. Small Business S. Hispanic-serving Institution T. Historically Black Colleges and Universities HBCUs U. Tribally Controlled Colleges and Universities TCCUs V. Alaska Native and Native Hawaiian Serving Institutions W. Non-domestic non-US Entity X. Other specify