TEGL_26_11_Change1.Final.pdf

ETA Advisory File Text

June 6 2012 26-11 Change 1 OMB Number 4040-0004 Expiration Date 01 31 2009 Application for Federal Assistance SF-424 Version 02 1. Type of Submission Preapplication Application Changed Corrected Application 2. Type of Application New Continuation Revision If Revision select appropriate letter s Other Specify 3. Date Received 4. Applicant Identifier 5a. Federal Entity Identifier 5b. Federal Award Identifier State Use Only 6. Date Received by State 7. State Application Identifier 8. APPLICANT INFORMATION a. Legal Name b. Employer Taxpayer Identification Number EIN TIN c. Organizational DUNS d. Address Street 1 Street 2 City County State Province Country Zip Postal Code e. Organizational Unit Department Name Division Name f. Name and contact information of person to be contacted on matters involving this application Prefix First Name Middle Name Last Name Suffix Title Organizational Affiliation Telephone Number Fax Number Email OMB Number 4040-0004 Expiration Date 01 31 2009 Application for Federal Assistance SF-424 Version 02 9. T ype 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 11. Catalog of Federal Domestic Assistance Number CFDA Title 12 Funding Opportunity Number Title 13. Competition Identification Number Title 14. Areas Affected by Project Cities Counties States etc. 15. Descriptive Title of Applicant s Project OMB Number 4040-0004 Expiration Date 01 31 2009 Application for Federal Assistance SF-424 Version 02 16. Congressional Districts Of a. Applicant b. Program Project 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 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 Authorized for Local Reproduction Standard Form 424 Revised 10 2005 Prescribed by OMB Circular A-102 OMB Number 4040 -0004 Expiration Date 01 31 2009 Application for Federal Assistance SF-424 Version 02 Applicant Federal Debt Delinquency Explanation The following should contain an explanation if the Applicant organization is delinquent of any Federal Debt. INSTRUCTIONS FOR THE SF-424 This is a standard form required for use as a cover sheet for submission of pre-applications 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 fields on the form are identified with an asterisk and are also specified as Required in the instructions below. In addition to these instructions applicants must consult agency instructions to determine other specific requirements. Item Entry Item Entry 1. Type of Submission Required Select one type of submission in accordance with agency instructions. Pre-application Application Changed Corrected Application Check if this submission is to change or correct a previously submitted application. Unless requested by the agency applicants may not use this form to submit changes after the closing date. 10. Name Of Federal Agency Required Enter the name of the federal agency from which assistance is being requested with this application. 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. 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 D. Decrease Duration B. Decrease Award E. Other specify C. Increase Duration 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. 14. Areas Affected By Project This data element is intended for use only by programs for which the area s affected are likely to be different than the place s of performance reported on the SF-424 Project Performance Site Location s Form. Add attachment to enter additional areas if needed. 3. Date Received Leave this field blank. This date will be assigned by the Federal agency. 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 pre-applications attach a summary description of the project. 4. Applicant Identifier Enter the entity identifier assigned buy the Federal agency if any or the applicant s control number if applicable. 5a. Federal Entity Identifier Enter the number assigned to your organization by the federal agency if any. 16. Congressional Districts Of 15a. Required Enter the applicant s congressional district. 15b. 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 5 th district CA-012 for California 12 district NC-103 for North Carolina s 103 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. This optional data element is intended for use only by programs for which the area s affected are likely to be different than place s of performance reported on the SF-424 Project Performance Site Location s Form. Attach an additional list of program project congressional districts if needed. 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 a. Legal Name Required Enter the legal name of applicant that will undertake the assistance activity. This is the organization that has registered with the Central Contractor Registry CCR . Information on registering with CCR may be obtained by visiting www.Grants.gov. 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 www.Grants.gov. 19. Is Application Subject to Review by State Under Executive Order 12372 Process Required 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 address Street 1 Required city Required County Parish State Required if country is US Province Country Required 9-digit zip postal code Required if country US . 20. Is the Applicant Delinquent on any Federal Debt Required Select the appropriate box. This question applies to the applicant organization not the person who signs as the authorized representative. Categories of federal debt include but may not be limited to delinquent audit disallowances loans and taxes. If yes include an explanation in an attachment. e. Organizational Unit Enter the name of the primary organizational unit department or division that will undertake the assistance activity. f. Name and contact information of person to be contacted on matters involving this application Enter the first and last name Required prefix middle name suffix title. Enter organizational affiliation if affiliated with an organization other than that in 7.a. Telephone number and email Required fax number. 21. Authorized Representative To be signed and dated by the authorized representative of the applicant organization. Enter the first and last name Required prefix middle name suffix. Enter title telephone number email Required and fax number. 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. Private Institution of Higher Education O. Individual P. For-Profit Organization Other than Small Business Q. Small Business R. Hispanic-serving Institution S. Historically Black Colleges and Universities HBCUs T. Tribally Controlled Colleges and Universities TCCUs U. Alaska Native and Native Hawaiian Serving Institutions V. Non-US Entity W. Other specify APPLICATION FOR Version 7 03 FEDERAL ASSISTANCE 2. DATE SUBMITTED Applicant Identifier 1. TYPE OF SUBMISSION 3. DATE RECEIVED BY STATE State Application Identifier Application Preapplication Construction Construction 4. DATE RECEIVED BY FEDERAL AGENCY Federal Identifier X Non-Construction Non-Construction 5. APPLICANT INFORMATIONLegal Name Organizational Unit Department Organizational DUNS Division Address Name and telephone number of person to be contacted on matters Street involving this application give area code Prefix First Name City Middle Name County Last Name State Zip Code Suffix Country Email 6. EMPLOYER IDENTIFICATION NUMBER EIN Phone Number give area code Fax Number give area code 8. TYPE OF APPLICATION 7. TYPE OF APPLICANT See back of form for Application Types State New Continuation Revision If Revision enter appropriate letter s in box es Other specify See back of form for description of letters. Other specify 9. NAME OF FEDERAL AGENCY 10. CATALOG OF FEDERAL DOMESTIC ASSISTANCE NUMBER 11. DESCRIPTIVE TITLE OF APPLICANT S PROJECT TITLE Name of Program Public Health and Social Services Emergency Fund 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. Federal THIS PREAPPLICATION APPLICATION WAS MADE a. YES. AVAILABLE TO THE STATE EXECUTIVE ORDER 12372 b. Applicant PROCESS FOR REVIEW ON c. State DATE d. Local b. NO. PROGRAM IS NOT COVERED BY E.O. 12372 e. Other OR PROGRAM HAS NOT BEEN SELECTED BY STATE FOR REVIEW f. Program Income 17. IS THE APPLICANT DELINQUENT ON ANY FEDERAL DEBT g. TOTAL Yes. If Yes attach an explanation. No. 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. Authorized RepresentativePrefix First Name Middle Name Last Name Suffix b. Title c. Telephone Number give area code d. Signature of Authorized Representative e. Date Signed Previous Edition Usable Standard form 424 Rev.9-2003 Authorized for Local Reproduction Prescribed by OMB Circular A-102 - - - - - OMB Approval No. 0348-0044 SECTION A - BUDGET SUMMARY Grant Program Catalog of Federal Estimated Unobligated Funds New or Revised Budget Function Domestic Assistance Number or Activity Federal Non-Federal Federal Non-Federal Total a b c d e f g 1 0 0 2 3. 4. 5. TOTALS 0 0 SECTION B - BUDGET CATEGORIES GRANT PROGRAM FUNCTION OR ACTIVITY Total 5 3 4 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 i. Total Direct Charges sum of 6a - 6h 0.00 0.00 k. TOTALS sum of 6i and 6j 0.00 BUDGET INFORMATION -- Non-Construction Programs 6. Object Class Categories a. Personnel b. Fringe Benefits c. Travel d. Equipment e. Supplies f. Contractual g. Construction h. Other j. Indirect Charge 7. Program Income a Grant Program b Applicant c State d Other Resources e TOTALS 0 0 0 0 0 SECTION D - FORECASTED CASH NEEDED Total for 1st Year 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter SECTION E - BUDGET ESTIMATES OF FEDERAL FUNDS NEEDED FOR BALANCE OF THE PROJECT FUTURE FUNDING PERIODS YEARS b First c Second d Third e Fourth 0.00 0 0 0 20. Totals sum of lines 16-19 0.00 Attach additional Sheets if Necessary 21. Direct Charges 22. Indirect Changes Prelimary Indirect Cost Rate SF 424A 4-88 Page 2Prescribed by OMB Circular A-102 SECTION C - NON-FEDERAL RESOURCES 8. 9. 10. 11. 12. TOTALS sum of lines 8-11 18. 19. SECTION F - OTHER BUDGET INFORMATION 23. Remarks 13. Federal 14. NonFederal 15. TOTAL sum of lines 13 and 14 Grant Program 17.