TEGL_26_11_Change1_Att7.pdf

ETA Advisory File Text

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.