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Attachrrent M GENERAL INSTRUCTIONS This is a multi-purpose standard form. First, it will be used by applicants as a required tacesh~t for pi"e-applications and applications submitted in accOfdance with OMB Circular A-102. Second, it will be used by Fweral agencies to report to clearinghouses on major actions taken on applications reviewed by clearinghouses in accordance with OMB Drcular A-95. Third, it will be used by Federal agen<::les to notify States ot grantS-In-aId awarded in accordance with Treasury Circular 1082. Fourth, it may be used. on an optional basIs, as a notification of intent from applicants to clearinghouses, as an early inItial notice that Federal assistance is to be applied for (clearinghouse procedures will govern). APPLICANT PROCEDURES FOR SECTION I A,-'Ç1.cant ",111 complete all Items In Secoon I If an rtem IS not"lP9llCabte. wri1e "NA". It addrtlOnal space IS ~, In~ an as!e"s,< .,... ..,xj u;¡.e In.e remar..s secuon on Ir'.~ œç~ ot the form An expjàr.al>on folo".~ ICf Bach rtern. t/1m1 118m 1. Man.. app<opnate box Pre.appìocaoon and applICatIOn 10 GO'o/em ,"",,-r. tal ~nlt wheoe Slgnthcanl and meanlnglul 1m. gUIdance IS In OMB c.rcular A-102 and Fedefal agency paC! could De 005e<ved. Llsl only largeSI unit Ot units program instructiOns. NOlihcatiOn 01 Intent 9""Jance 1$ In aHected. s.u<:h as Sta'e. county. or CIty If entire unit c.rcular A-95 and procedures from cleannghOU$e Apph. aHeçted, list It ratl'!er than subun.1s C)ant ""II not use "Repot1 01 Feòeral Action" box. 11. EstImated numœt 01 persons c.racfty benefItIng from 2a Applicant s own control number, II desired pr~t 2b. Date SectIon j 's Ç<€t)ared 12 US?- app<opnaie code let1e,. DeflT1ltJOns are. 3a Number aSSIgned by State cleannghouse, or If óe!eg4ted A. N"", A SU!Jm.ttal for toe t"st lion+) for a new pto!"cl by Stale, by areaWIde cleannghouse. Ail rðq\Æsls to B. Rer>e'Wal An aX1enSlon IOf an adalliona! funding! Federal agencies must contain tn,s ldentlfter if the pro- ~flt pe1X)d Ie< a profect hav'ng no prOtected com- gram IS covered by Circular A-95 and reqUIred by awllca. ple1lOr. date. but tor which Federal support musl be ble State/areawide cleaf'nghoùse Ç<ocedures tf in rer>ewed each yei" doùbt. consult your clean",;;;'ous¿ 3h Date apphcant notllled of c;.""nnghOUse identifIer. C R6V1s.on A rrxxj¡hcahon to OfO¡ecl nature or seOp.? wh¡çt¡ rr>.ay result In íund'ng change {Increase or de. 4a-4h. Legal name of applicanl/raclptenl. name 01 pornary Ofga- crease) nLZatlonal Unit which ....,11 unclet'Uke the asSlstançe act IV, O. ContinuatIOn An eX1enSlon IOf an addItIOnal funding I Jty, complete address of aj)piiCant, and name and bu(jçet period fOf a projeCt the agency InItIally agre-e{j telephone number of person whO can provide further to lund IOf a c.!ef!nlte number ot years Information about th,s request E. AugmentatlOO A reqUirement 10< addltiOnallunds lor a 5. Employer ldenbhcahon number 01 applicant as aSSIgned pr~t prev>c>usly awarded fund:> in the same lundtng! by Intemal Revenue SeNK:e ~t period. PrOeCt natu,e and :;cope unchanged 6<1. Use Catalog 01 Fedefal [)omestJc ASSIstance number 13. Amo.mt requested Of to be contnbu1ed dunng the first as$lgned to program undef whiCh asSIstance is request- fundlng/Dodget penod by each contnbutor Value 01 In- ed II more than one program (eg.. joont-fundlng) wnte kind cootntutlOnS WIll be mc!ude-d il the action IS a "mult,ple" and explain in reman..s. If unl(nown. cite Pub!(; cha"9" In dollar amount of an exls:jng grant (a r€'VISlon or Law or U.S. Code augmentat>Of1). ind>cale only the amount 01 the CI'.3nge 6b. Program title Irom Fedefal Catalog. AbOI'EIVI3te if neces. FOf óecreases enclose the arnoun1 (1 pa'entheses II both baSK: and supplemental amounts are Included, sary break out In reman..s. FOf multiple Ç<OÇfam fund,ng. use 7. Boef title and appropnate description 01 prOeCt. For tolals and ShOw program breakouts ,n remarks Item notiflCat'on of In lent. conbnue In reman..s sectIOn II neces. def,MiCf1S: 13a. amount requested from Federal Govern. sary to convey proper descnplton. ment; 13b. amount aw~cant WIll contnbute; 13c. amount ß. Mostly self-explanatory. "c.ty" Includes town, townshtp Of from State. if appIiC8nt IS not a State; 13<1. amount from other municipality local go...emment. if applIcant IS not II local government; 9 CMck the type(s) of il8al$t8nœ requested, The Oefini- 1:!e. amount from aft'{ other sources, explain '" remarl<s tJoru¡ 01 the terms are: 14a. Seff explanatory. A. BaSIc Grant. An a1Çina1 f$QI.I6St for Fed«al funds. 14b. The dlstnct(sl where most 01 actual worX will be acoom- nus would not ioc!ode any contnbution pI'OYided un- p!oshed. 11 crty--=se or Stal~wIde. COVfIring !IeVerai dls- óer a supplemental grllnt. tncts,....me "crty--oe" or "Stale-woOe." B. SuP9lemental Grant. A request to increase . baSK: 15. Compóele ~ for ~s (rt6m t2c), or augmentatIOns Çjf'ant In certain cases where the eIogòbe IIppbcant (item 12e). cannot supply the r<aquorlKl matc;nu,g BNlrf) of the 16. Approximate c»te prOElct expected to begin (usually ai>- Ca3ic FecIe<al pt':)gam (eg.. grants awarded by the Appalðchoan R~¡ Comf/1lSSOO 10 ¡:royIde the ooo;ated I!oIittI 8$bmated dale 01 availability oIlunding) 4\WIocanl a malchong 3hare 17. E!ltJmaled number of months to ~te pI'OðCl lI"er F~I !ut'>ds are aV1Ulðble C. Lœn. Self expia""'ICfY. 18. fsl1matlKl c.te pt"e-ttppIiC8tJOn/appiocatJOn will be !IUbrl\¡t. O. ln5Ufanoe. s.Kf exp¡.anatory. lee to FÐÓe<al ~/X:'f if this prOoElct reoquores cleanog. 11ous.a rtI'V>eW II r~ ('.N reQtllroo, thIS dale WD<Jld E. 0ti7ðr Explain on rl!'l'1'dr1<s page usually be Mm I>r.uooARO~42,p~31"'" '.771 EYhibit !vI-- 3. App li ca ti on for Federal Assistance (NJnconstruction Progr a:rrs) (Pac;,e 3 of 13) 13