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~1achIœnt M Ilem 19. EJostlng Federal ídet1tiflCðtion number if thIS is not a new 20. Indicate Feden~1 agency to which this request is ad- request and directly r~tes to It previous Federal action. dressed. Street address not required. bu1 do use ZIP. Oth-efWÍse write "NA" 21. Clreck appropriate box as to whether Section IV of lorm contains remarks and/or additional remarks are attached. APPLICANT PROCEDURES FOR SECTION II Applicants will always complete items 23a. 23b. and 23c. If cJearinghouse reVIeW is reqUITed. item 22b must be fully completed. An explanat,on follows for each item. Irem Item 22b liS! cleannghouses to which submItted and show in 230 Self expíanatory appropriate blocks the status of theIr responses For mOfe than three cleannghouses. continue in .remarks Self explanatory :x:cllon All v,-nt1en comments submrtted by or through 23c claannghouses must be attached 23a Name and title of authorized representative of I~al Note Apphcant completes only SectIons I and II. Section III IS <:pplican! completed by Feelerai aÇ€nC18S fEDERAL AGENCY PROCEDURES FOR SECTION m II appl¡cant.supphed information In SoBc(>,')ns I and II needs no updating or adlustment to fit the final Federal action, the. Federal agency WIll complete Section III Only An explanallOf1 fOf each Item fol1ows flem {(em 24. Executive depàr1ment or Independent agency having pro- 35 Name and telephone no of agency person who can gram administration responsibdl!y prm;¡c!e m(){e information regarding this assistance 2S SoBi! explanatory 36 Dale after which funds will no longer be available. 26. Primary organ!zahonai un!' below department level having 37 Check appropnate box as to whether Section IV of lorm direct program management respons!bill~f contaIns Federal remarks and/or attachment of add'tlon- '2ì Office dJfectly monltonng the program. al remarks. 26 Use to 10\'"tl1)< non.award actions where Federal grant 38 For use WIth A-95 actIon notices only. Name and tete- Identifier iO Item 30 IS not applicable or WIll not suffice phone 01 person who can assure that appropnate A-95 actIOn has been taken-If same as person shown In item 29 Complete address of aamintstering offIce shown In Item 35. wnte "same". If not applicable. write UNA". 26 30 Use to ,denhfy award actIons where dIfferent frorn Feder. Federal Agency Procedures-special conSIderations al application IdenCJIler In Item 28. A. Treasury Clrcu{ar 1082 compliance Fe.jar,,1 agency will assure 31. Self explanatory Use remarks section to amplify where pro~r completion of Sections I and III If Section I is beIng appropflate completed by Federal agency. all applicable items must be hlled 32 Amounf to be contribUted dunng the nrst funding/blKlget In. Addresses of State information RecaptIOn AgenCies pariO<! by eac.h contributor. Value of in-kind contributions (SCIRA's) are provided by Treasury Department to each agency. \hill be included If the actIon is a change in dollar This form replaces SF 240. which will no longer be usee!. amount of an exIsting grant (a rENi~on or Bt.'9mentation), B. OMS Clrcu{ar A-95 cornpliance Federal agency will assure IndIcate only the amoimt of change. For decreases, p4'oper completion of Sections I. II. and III. THis form is required enclose the amount in parentheses. If both basic and to( notifying all reviewing clearinghouses ofma¡or actions on all supplemental amounts are included. break out in remarks. programs reviewed under A-95. Addresses of State and For mul"ple program f'.IndH19. use totals and show pro. weawide clæringho..¡sas are pr~ by OMS to each agency gram breakouts 10 remarks. Item definitIOns: 3213, amount SubstantiVe differences between applicant's request and/or awarded by Federal Government; 32b. amount applicant clearinghouse rÐCOmmelXlatlOf1s. and the project as finally will contribute; 32c. amount !rorn State. if appIir..anl is not _arded will be explained in A-95 ooliiicniions to clearing- a Stale; 32d. amount from !0C31 government if apphc.ant is houses not a local government; 32e. amount from any ottwr C Spec..afnofe. fn most. but not 1'11/ SUItes, the A-9S Stale cleanng. oources. axplalO '" remarlls. !'.ouse and the (TC 1082) SCIRA are the same offIce. In such 33 Dam action was taken on this req\.WsL cases. the A-95 award notJCe to !he Sta1e daaringhouse ",iil fuffill the TC 1082 award "'".tics requirement to the State SC!RA 34 Date funds wi!! become ava;iab!e. Duphcale notrfJC800n should be avoided. Exhibit 11-3. Application for Federal Assistance (Nbnconstruction PrograITs) (Page 4 of 13) IIT~ fOllOW aM 1"AQf;. (Hev 4-77) 14