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FIGURE 1 (Continued) Standard Form 424 INSTRUCTIONS FOR THE SF 424 Public reporting bW'den for this collection- of infonnation is estimaled to average 45 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of infonnation. Send commentS regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget. Paperwork Reduction Project (0348-0043), Washington, DC 205030 PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET, SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY. This is a standard fonn used by applicantS as a required facesheet for preapplications and applications submitted for Federal assistance. It will be used by Federal agencies to obtain applicant cenification that States which have established a review and comment procedure in response to Executive Order 12372 and have selecled the program to be included in their process, have been given an oppornmity to review the applicant's submission. Item: Entry: Item: En try : 1. Self-explanaLOryo 12. List only the largest political entities affected (e.g., State, 20 Date application submiued to Federal agency (or State if counties, cities)o applicable) & applicant's control number (if applicable). 13. Self-explanatory. 30 State use only (if applicable). 140 List the applicant's Congressional District and any 40 If this application is to continue or revise an existing District(s) affected by the program or project. award, enter present Federal identifier number. If for a 150 Amount requested or to be contribuled during the flI'St new project, leave blank. funding/budget period by each conttibutoro Value of in- 5. Legal name of applicant, name of primary organizational kind conuibutions should be included on appropriate lines unit which will undertake the asSistance activity, complete as applicableo If the action will result in a dollar change to address of the applicant, and name and telephone number an existing award, indicate .G!lÚ.Y-the amount of the change. of the perSQJ'lto contact on mauers related to this For decreases, enclose the amountS in parentheses. If both applicationo basic and supplemenUlI amounts are included, show 60 Enter Employer Identification Number (EIN) as assigned breakdown on an attached sheet. For multiple program funding, use totals and show breakdown using same by the Internal Revenue Serviceo categories as item 15. 7. Enter the appropriate leuer in the space provided. 160 ApplicantS should contact the State Single Point of 80 Check appropriate box and enter appropriate leuer(s) in Contact (SPOC) for Federal Executive Order 12372 to the space(s) provided: determine whether the application is subject to the State - "New" means a new assistance award. intergovernmental review processo - "Conúnuation" means an extension for an additional 17. This question applies to the applicant organization. not funding/budget period for a project with a projected the person who signs as the authorized representative. completion dateo Categories of debt include delinquent audit disallowances. loans and taxes. - "Revision" means any change in the Feœral 180 To be signed by the authorized representative of the Government's financial obligaúon or contingent liability from an existing obligation. applicanL A copy of the governing body's authorization for you to sign this application as official representative 9. Name of Federal agency from which assistance is being must be on file in the applicant's office. (Certain Federal requested with this application. agencies may require that this authorization be submitted 100 Use the Catalog of Federal Domestic Assistance number as pan of the applicationo) and title of the program under which assistance is requested. 110 Enter a brief descriptive title of the project. If more than one program is involved, you should append an explanation on a separate sheet. If appropriate (e.g., constrUction or real propeny projects), attach a map showing project location. For preapplications, use a separate sheet to provide a summary description of this project. SF 424 Back (Rev. 4-92) 4