Standard Form 424 - Us Embassy In Albania
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1Standard Form 424
APPLICATION FOR
OMB Approval No. 0348-0043
FEDERAL ASSISTANCE
2. DATE SUBMITTED
Applicant Identifier
1. TYPE OF SUBMISSION:
3. DATE RECEIVED BY STATE
State Application Identifier
Application:
Preapplication:
______ Construction
______ Construction
4. DATE RECEIVED BY FEDERAL AGENCY
Federal Identifier
______ Non-Constuction
______ Non-Constuction
5. APPLICANT INFORMATION
Legal Name:
Organizational Unit:
Address (give city, county, state, and zip code):
Name and telephone number of person to be contacted on matters involving this
application (give area code)
6. EMPLOYER IDENTIFICATION NUMBER (EIN):
7. TYPE OF APPLICANT: (enter appropriate letter in box)
A. State
H. Independent School Dist.
8. TYPE OF APPLICATION
B. County
I. State Controlled Institution of Higher Learn.
C. Municipal
K. Indian Tribe
___ New
___ Continuation
___ Revision
D. Township
L. Individual
E. Interstate
M. Profit Organization
F. Intermunicipal
N. Other (Specify): ____________________
If Revision, enter appropriate letter(s) in box(es)
G. Special Dist.
A. Increase Award
D. Decrease Duration
B. Decrease Award
E. Other (specify): _______________
C. Increase Duration
9. NAME OF FEDERAL AGENCY:
___________________________
10. CATALOG OF FEDERAL DOMESTIC ASSISTANCE NUMBER:
11. DESCRIPTIVE TITLE OF APPLICANT'S PROJECT:
TITLE:
12. AREAS AFFECTED BY PROJECT (Cities, Counties, States, etc.):
13. PROPOSED PROJECT
14. CONGRESSIONAL DISTRICTS OF:
START DATE
END DATE
a. Applicant
b. Project
15. ESTIMATED FUNDING:
16. IS APPLICATION SUBJECT TO REVIEW BY STATE EXECUTIVE
ORDER 12372 PROCESS?
$
a. Federal
$
b. Applicant
a. YES. THIS PREAPPLICATION/APPLICATION WAS MADE AVAILABLE
TO THE STATE EXECUTIVE ORDER 12372 PROCESS REVIEW ON:
$
c. State
$
d. Local
DATE ___________________________
$
e. Other
b. NO. ___ PROGRAM IS NOT COVERED BY E.O. 12372
$
f. Program Income
___ OR PROGRAM HAS NOT BEEN SELECTED BY STATE FOR REVIEW
$
-
g. TOTAL
17. IS THE APPLICANT DELINQUENT ON ANY FEDERAL DEBT?
___ Yes
If "Yes," attach an explanation.
___ No
18. TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL DATA IN THIS APPLICATION/PREAPPLICATION 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.
a. Type Name of Authorized Representative
b. Title
c. Telephone Number
d. Signature of Authorized Representative
e. Date Signed
Previous Edition Usable
Standard Form 424 (REV 4-92)
Authorized for Local Representative
Prescribed by OMB Circular A-102
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Parent category: Legal