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Electronic Grant Information Verification And Evaluation System

Grant Application - Standard Form 424 

1. Type of Submission

 Applicant Information  Pre-Applicant Information

 Construction                     Construction

           Non-Construction           Non-Construction		 2. Date Submitted 

3. Date Received By State 

4. Date Received By Fed. Agency

CFDA Number

 

 
Applicant Identifier 

State Applicant Identifier. 

Federal Identifier 

 Organizational Unit 
Legal Name 
Address -Street No. 1 
Address -Street No. 2 
City Name 
City - FIPS Code 
County Name 
County FIPS Code 
State 
State FIPS Code 
Zip Code 
Zip Code-4 
Name and Contact Information 
 Title 
First Name 
Middle Initial 
Last Name 
Phone Number 
FAX Number 
Email Address 
6. Employer Identification Number (EIN)  Name of Federal Agency

8. Type of Application

New Continuation Revision 

If Revision, check appropriate box:

A. Increase Award 
B. Decrease Award 
C. Increase Duration

D. Decrease Duration 
E. Other (Specify): 
Type of Applicant (Check Appropriate Box) 
A. State 
B. County 
C. Municipal 
D. Township
E. Interstate 
F. Inter-municipal 
G. Special District 
H. Independent School Dist.
I. State Controlled Inst.of Higher Learning 
 J. Private University 
K. Indian Tribe 
L. Individual 
M. Profit Organization 

N. Other (Specify) 
10. Catalog of Domestic Federal Assistance Number 

Title 

 11. Descriptive Title of Applicant's Project: 

12. Areas Affected By Project 
City No. 1 
City No. 2 
City No. 3 
City No. 4 
City No. 5 
Cnty No. 1 
Cnty. No. 2 
Cnty No. 3 
Cnty. No. 4 
Cnty. No. 5 
State No. 1 
State No. 2 
State No. 3 
State No. 4 
State No. 5 
Applicant Congressional District: 

Congressional District No. 1 
Congressional District No.2 
Congressional District No. 3 
Congressional District No.4 
Congressional District No. 5 

Project Congressional District: 

P. Congressional Dist. No. 1 
P. Congressional Dist. No. 2 
P. Congressional Dist. No. 3 
P. Congressional Dist. No. 4 
P. Congressional Dist. No. 5 
13. Proposed Project    Start Date 

      Proposed Project End Date 

 13. Proposed Project 
15. Estimated Funding 

A. Federal                        $

B. Applicant                      $

C. State                            $

D. Local                           $

e. Other                           $

F. Program Income           $

g. Total                             $

 16. Is Applicant Subject To Review By State Executive Order 12372 Process?

A. Yes This pre-application/application was made available to the StateExecutive Order 12372 Process For Review On: 

B. No: Program is Not Covered By Executive Order  12372

B. No:  Program Was Not Selected By State For Review
  Is Applicant Delinquent on Any Federal Debt?

Yes: 

Explanation: 

No: 
18. TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL DATA IN THIS APPLICATION/PRE-APPLICATION 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. 
Type Name of Authorized Representative 

 

 Title 

Phone Number: 
Signature of Authorized Representative 

Date Signed: 

This information will be submitted to the Grants Management Division