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This is a standard form used by applicants as a required facesheet for preapplìcations and applications submittf J in accordance with QMB Circular A-1 02. It will be used .by Federal agencies to obtain applicant certification that states which hE Ie eëtablished a review and comment procedure in response to Executive Order 12372 and have selected the program to be .ncluded in their process have been given an opportunity to review the applicant's submission. APPLICANT PROCEDURES FOR SECTION I Applicant will complete all items in Section I with the exception of Box 3, "State Application Identifier." If an item is not applicable, WI1te "NA." If additional space is needed, insert an asterisk ".," and use Section IV. An explanation follows for each item: Item 1. Mark appropriate box. Preapplication and application are described in OMB Circular A-102 and Federal agency program instructions. Use of this form as a Notice of Intent is at State option. Federal agencies do not require Notices of Intent. Applicant's own control number, if desired. Date Section lis prepared (at applicant's option). Number assigned by State. 3b. Date assigned by State. 4a-4h. legal name of applicant, name of primaty organizational unit which will undertake the 8S8is1ance activi1y, complete address of applicant, and name and telephone number of the person who can provide further information about this request. Employer Identification Number (EIN) of applicant as assigned by the Internal Revenue Service. Use Catalog of Federal Domestic Assistance (CFDA) number assigned to program under which assistance is requested. If more than one program (e.g.. joint funding), check "multiple" and explain in Section IV. If unknown, cite Public Law or U.S. Code. Program title from CFDA. Abbreviate If necessary. Use Section IV 10 provide a summary description of the project. If appropriate. i.e., if project affects particular sites as, for example. construction or real property projec':;:I. attach a map showing the project location. "City" includes town, township or other municipality. li~t only largest unit or units aHected, such as State, county, or city. Estimated number of persons directly ~nefiting from project. Check the type(s) of assistance requested. A. Basic Grant-an original request for Federal funds. B. Supplemental Grant-a request to increase a basic grant in certain ~ses where the eligible applicant cannot supply the required matching share of the basic Federal program (e.g., grants awarded by the Appalachian Regional Commission to provide the applicant a matching share). E. Other. Explain in Section IV. Amount requested or to be contributed during the first funding/budget period by each contributor. Value of in-kind contributions should be included. If the action is a change in dollar amount of an existing grant 5. 68. 6b. 7. 8. 9. 10. 11. 12. Item 13b. (a revision or augmentation under item 1<4). indIca1e on;y the amount of the change. For decreases, enclose the amount in )<;'~";~./!!8. If both basic and supplemental amounts ant included, ~/;ç.::;,i In Sdon IV. For multiple program funding. use totals and Vtow p¡-;:;;~ maXouts in Section IV. 12a-arnount requested from F&'J~:'Z! Government. 12o-amount applicant will contribu1e. 12o--M'1OUnt from State, if applicant is not a State. 12d-amount from IoœJ government, if applicant is not a local government. \2e---e.mount 1.om 'I.r'tf other sources, explain in Section IV. The district(s) where mos1 of action work wiIf be accompli$hed. If city- wide or State-wide, covering several diltrict8. write "city-wide" or "State-wide." 14. A. New. A submittal for project not previously funded. B. Renewal. An extension for an additional funding/budget period for . project having no projected completion date. but tor which Federal support must be renewed each year. C. Revision. A modification to project nature or scope which may resuh in funding change (increase or decreue). D. Continuation. An extension for an additional funding/budget period for a project with a projected Completion date. E. Augmentation. A requirement for additional funds for a project previously awarded funds in the same funding/budget period. Project nature and scope unchanged. Approximate date project expected to begin {usually associated with estimated date of availability of funding}. Estimated number of months to complete project after FederåI funds are available. Complete only for revisions (item '4c), or augmen1allons (item 148). Date preapplication/application must be submitted 10 Federal agency in order to be eligible fO( funding consideration. Name and address of the Federal agency to which !his request is addressed. Indicate as clearly as possible the name of the office to which the application will be delivered. Existing Federal grant identification number if this is not a new request and directly relates 10 a previous Federal action. Otherwise, write "NA." 15. 16. 11. 18. '9. 20. 21. Check appropriate box as to whether Section N of form contains remarks and/or additional remarks are attached. APPLICANT PROCEDURES FOR SECTION II Applicants will always complete either item 22a or 22b and items 23a and 23b. 22a. Complete if application is subject to Executive Order 12372 (Slate 22b. review and comment). 23a. Check if application is not subject to EO. 12372. Name and title of authorized representative of 18081 applicant. FEDERAL AGENCY PROCEDURES FOR SECTION III Applicant completes only Sections I and II. Section 1\1 Is completed by Federal agencies. 26. 27. 28. Use to identify award actions. Use Section IV to amplify where appropriate. Amount to be contributed during the first funding/budget period by each contributor. Value of in-kind contributions will be included. If the action is a change in dollar amount of an existing grant (a revision or augmentation under item 14), indicate only the amount of change. For decreases, enclose the amount in parentheses. If both Dasic and supplemental amounts are included. breakout in Section IV. For multiple program funding, use totals and show program breakouts in Section IV. 28&-emount awarded by Federal Government. 2Bt>-ðmount applicant 3 29. 30. 31. 32. 33. will contribute. 28c-amounl from State, If applicant is not a State. 28~mount from local government, if applicant is not a local govern.. ment. 28e-amounl from any other sources, explain in Section IV. Date action was taken on this request. Date funds will become available. Name a~ telephone number of agency peraon who can provide more information regarding this assistance. Date after Which funds will no longer be available for obligation. Check appropriate box as to whether Section IV of form contains Federal remarks and/or anachment of additional remarka. ..... ---