Fillable SF 424 Application Package (HHS)

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SF 424 Application Package (HHS)

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The SF 424 Application Package (HHS) form is 18 pages long and contains:

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  • 241 other fields

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Version 02
OMB Number: 4040-0004
Expiration Date: 01/31/2009
* 1. Type of Submission: * 2. Type of Application:
* 3. Date Received:
4. Applicant Identifier:
5a. Federal Entity Identifier: * 5b. Federal Award Identifier:
6. Date Received by State: 7. State Application Identifier:
* a. Legal Name:
* b. Employer/Taxpayer Identification Number (EIN/TIN): * c. Organizational DUNS:
* Street1:
Street2:
* City:
County:
* State:
Province:
* Country:
* Zip / Postal Code:
Department Name: Division Name:
Prefix: * First Name:
Middle Name:
* Last Name:
Suffix:
Title:
Organizational Affiliation:
* Telephone Number: Fax Number:
* Email:
* If Revision, select appropriate letter(s):
* Other (Specify)
State Use Only:
8. APPLICANT INFORMATION:
d. Address:
e. Organizational Unit:
f. Name and contact information of person to be contacted on matters involving this application:
Application for Federal Assistance SF-424
Preapplication
Application
Changed/Corrected Application
New
Continuation
Revision
USA: UNITED STATES
9. Type of Applicant 1: Select Applicant Type:
Type of Applicant 2: Select Applicant Type:
Type of Applicant 3: Select Applicant Type:
* Other (specify):
* 10. Name of Federal Agency:
11. Catalog of Federal Domestic Assistance Number:
CFDA Title:
* 12. Funding Opportunity Number:
* Title:
13. Competition Identification Number:
Title:
14. Areas Affected by Project (Cities, Counties, States, etc.):
* 15. Descriptive Title of Applicant's Project:
Attach supporting documents as specified in agency instructions.
Version 02
OMB Number: 4040-0004
Expiration Date: 01/31/2009
Application for Federal Assistance SF-424
* a. Federal
* b. Applicant
* c. State
* d. Local
* e. Other
* f. Program Income
* g. TOTAL
.
Prefix: * First Name:
Middle Name:
* Last Name:
Suffix:
* Title:
* Telephone Number:
* Email:
Fax Number:
* Signature of Authorized Representative: * Date Signed:
18. Estimated Funding ($):
21. *By signing this application, I certify (1) to the statements contained in the list of certifications** and (2) that the statements
herein are true, complete and accurate to the best of my knowledge. I also provide the required assurances** and agree to
comply with any resulting terms if I accept an award. I am aware that any false, fictitious, or fraudulent statements or claims may
subject me to criminal, civil, or administrative penalties. (U.S. Code, Title 218, Section 1001)
** The list of certifications and assurances, or an internet site where you may obtain this list, is contained in the announcement or agency
specific instructions.
Authorized Representative:
Authorized for Local Reproduction Standard Form 424 (Revised 10/2005)
Prescribed by OMB Circular A-102
OMB Number: 4040-0004
Expiration Date: 01/31/2009
Application for Federal Assistance SF-424
* a. Applicant
Attach an additional list of Program/Project Congressional Districts if needed.
* b. Program/Project
* a. Start Date: * b. End Date:
16. Congressional Districts Of:
17. Proposed Project:
Version 02
a. This application was made available to the State under the Executive Order 12372 Process for review on
b. Program is subject to E.O. 12372 but has not been selected by the State for review.
c. Program is not covered by E.O. 12372.
Yes No
** I AGREE
* 20. Is the Applicant Delinquent On Any Federal Debt? (If "Yes", provide explanation.)
* 19. Is Application Subject to Review By State Under Executive Order 12372 Process?
Version 02
OMB Number: 4040-0004
Expiration Date: 01/31/2009
The following field should contain an explanation if the Applicant organization is delinquent on any Federal Debt. Maximum number of
characters that can be entered is 4,000. Try and avoid extra spaces and carriage returns to maximize the availability of space.
Application for Federal Assistance SF-424
* Applicant Federal Debt Delinquency Explanation
INSTRUCTIONS FOR THE SF-424
Public reporting burden for this collection of information is estimated to average 60 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 information. 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 20503.
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 form (including the continuation sheet) required for use as a cover sheet for submission of preapplications and applications and
related information under discretionary programs. Some of the items are required and some are optional at the discretion of the applicant or the
Federal agency (agency). Required items are identified with an asterisk on the form and are specified in the instructions below. In addition to the
instructions provided below, applicants must consult agency instructions to determine specific requirements.
Item Entry: Item
Entry:
10.
Name Of Federal Agency: (Required) Enter the name of
the Federal agency from which assistance is being
requested with this application.
1.
Type of Submission: (Required): Select one type of submission in
accordance with agency instructions.
• Preapplication
• Application
• Changed/Corrected Application – If requested by the agency, check if this
submission is to change or correct a previously submitted application. Unless
requested by the agency, applicants may not use this to submit changes after
the closing date.
11.
Catalog Of Federal Domestic Assistance Number/Title:
Enter the Catalog of Federal Domestic Assistance number
and title of the program under which assistance is
requested, as found in the program announcement, if
applicable.
12.
Funding Opportunity Number/Title: (Required) Enter the
Funding Opportunity Number and title of the opportunity
under which assistance is requested, as found in the
program announcement.
13.
Competition Identification Number/Title: Enter the
Competition Identification Number and title of the
competition under which assistance is requested, if
applicable.
2.
Type of Application: (Required) Select one type of application in accordance
with agency instructions.
• New – An application that is being submitted to an agency for the first time.
• Continuation - An extension for an additional funding/budget period for a
project with a projected completion date. This can include renewals.
• Revision - Any change in the Federal Government’s financial obligation or
contingent liability from an existing obligation. If a
revision, enter the appropriate letter(s). More than one may be
selected. If "Other" is selected, please specify in text box provided.
A. Increase Award B. Decrease Award
C. Increase Duration D. Decrease Duration
E. Other (specify)
14.
Areas Affected By Project: List the areas or entities using
the categories (e.g., cities, counties, states, etc.) specified in
agency instructions. Use the continuation sheet to enter
additional areas, if needed.
3.
Date Received: Leave this field blank. This date will be assigned by the
Federal agency.
4.
Applicant Identifier: Enter the entity identifier assigned buy the Federal
agency, if any, or the applicant’s control number if applicable.
15.
Descriptive Title of Applicant’s Project: (Required) Enter
a brief descriptive title of the project. If appropriate, attach a
map showing project location (e.g., construction or real
property projects). For preapplications, attach a summary
description of the project.
5a.
Federal Entity Identifier: Enter the number assigned to your
organization by the Federal Agency, if any.
5b.
Federal Award Identifier: For new applications leave blank. For a
continuation or revision to an existing award, enter the previously assigned
Federal award identifier number. If a changed/corrected application, enter the
Federal Identifier in accordance with agency instructions.
6.
Date Received by State: Leave this field blank. This date will be assigned by
the State, if applicable.
7.
State Application Identifier: Leave this field blank. This identifier will be
assigned by the State, if applicable.
8.
Applicant Information: Enter the following in accordance with agency
instructions:
16.
Congressional Districts Of: (Required) 16a. Enter the
applicant’s Congressional District, and 16b. Enter all
District(s) affected by the program or project. Enter in the
format: 2 characters State Abbreviation – 3 characters
District Number, e.g., CA-005 for California 5th district, CA-
012 for California 12th district, NC-103 for North Carolina’s
103rd district. • If all congressional districts in a state are
affected, enter “all” for the district number, e.g., MD-all for all
congressional districts in Maryland. • If nationwide, i.e. all
districts within all states are affected, enter US-all. • If the
program/project is outside the US, enter 00-000.
a. Legal Name: (Required): Enter the legal name of applicant that will
undertake the assistance activity. This is ththat the organization has
registered with the Central Contractor Registry. Information on registering with
CCR may be obtained by visiting the Grants.gov website.
17.
Proposed Project Start and End Dates: (Required) Enter
the proposed start date and end date of the project.
b. Employer/Taxpayer Number (EIN/TIN): (Required): Enter the Employer
or Taxpayer Identification Number (EIN or TIN) as assigned by the Internal
Revenue Service. If your organization is not in the US, enter 44-4444444.
18.
Estimated Funding: (Required) Enter the amount
requested or to be contributed during the first funding/budget
period by each contributor. Value of in-kind contributions
should be included on appropriate lines, as applicable. If the
action will result in a dollar change to an existing award,
indicate only the amount of the change. For decreases,
enclose the amounts in parentheses.
c. Organizational DUNS: (Required) Enter the organization’s DUNS or
DUNS+4 number received from Dun and Bradstreet. Information on obtaining
a DUNS number may be obtained by visiting the Grants.gov website.
19.
Is Application Subject to Review by State Under
Executive Order 12372 Process? Applicants should
contact the State Single Point of Contact (SPOC) for Federal
Executive Order 12372 to determine whether the application
is subject to the State intergovernmental review process.
Select the appropriate box. If “a.” is selected, enter the date
the application was submitted to the State.
d. Address: Enter the complete address as follows: Street address (Line 1
required), City (Required), County, State (Required, if country is US),
Province, Country (Required), Zip/Postal Code (Required, if country is US).
20.
Is the Applicant Delinquent on any Federal Debt?
(Required) Select the appropriate box. This question applies
to the applicant organization, not the person who signs as
the authorized representative. Categories of debt include
delinquent audit disallowances, loans and taxes. If yes,
include an explanation on the continuation sheet.
e. Organizational Unit: Enter the name of the primary organizational unit
(and department or division, (if applicable) that will undertake the assistance
activity, if applicable.
f. Name and contact information of person to be contacted on matters
involving this applicat required), organizational affiliation (if affiliated with an
organization other on: Enter the name (First and last name than the applicant
organization), telephone number (Required), fax number, and email address
(Required) of the person to contact on matters related to this application.
21.
Authorized Representative: (Required) To be signed and
dated by the authorized representative of the applicant
organization. Enter the name (First and last name required)
title (Required), telephone number (Required), fax number,
and email address (Required) of the person authorized to
sign for the applicant. A copy of the governing body’s
authorization for you to sign this application as the official
representative must be on file in the applicant’s office.
(Certain Federal agencies may require that this
authorization be submitted as part of the application.)
Type of Applicant: (Required) Select up to three applicant type(s) in
accordance with agency instructions.
9.
A. State Government
B. County Government
C. City or Township
Government
D. Special District Government
E. Regional Organization
F. U.S. Territory or Possession
G. Independent School District
H. Public/State Controlled
Institution of Higher
Education
I. Indian/Native American
Tribal Government
(Federally Recognized)
J. Indian/Native American
Tribal Government (Other
than Federally Recognized)
K. Indian/Native American
Tribally Designated
Organization
L. Public/Indian Housing
Authority
M. Nonprofit
N. Nonprofit
O. Private Institution of
Higher Education
P. Individual
Q. For-Profit Organization
(Other than Small
Business)
R. Small Business
S. Hispanic-serving
Institution
T. Historically Black
Colleges and
Universities (HBCUs)
U. Tribally Controlled
Colleges and
Universities (TCCUs)
V. Alaska Native and
Native Hawaiian Serving
Institutions
W. Non-domestic (non-US)
Entity
X. Other (specify)
BUDGET INFORMATION - Non-Construction Programs
OMB Approval No. 0348-0044
SECTION A - BUDGET SUMMARY
Grant Program
Function
or Activity
(a)
Catalog of Federal
Domestic Assistance
Number
(b)
Estimated Unobligated Funds New or Revised Budget
Federal
(c)
Non-Federal
(d)
Federal
(e)
Non-Federal
(f)
Total
(g)
1.
$ $ $ $ $
2.
3.
4.
5. Totals
$ $ $ $ $
SECTION B - BUDGET CATEGORIES
6. Object Class Categories
GRANT PROGRAM, FUNCTION OR ACTIVITY Total
(5)
(1) (2) (3)
a. Personnel
$ $ $ $ $
b. Fringe Benefits
c. Travel
d. Equipment
e. Supplies
f. Contractual
g. Construction
h. Other
i. Total Direct Charges
(sum of 6a-6h)
j. Indirect Charges
k. TOTALS
(sum of 6i and 6j)
$ $ $ $ $
7. Program Income $ $ $ $ $
Authorized for Local Reproduction Standard Form 424A (Rev. 7-97)
Previous Edition Usable
Prescribed by OMB Circular A-102
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SECTION C - NON-FEDERAL RESOURCES
(a) Grant Program (b) Applicant (c) State (d) Other Sources (e) TOTALS
8. $ $ $ $
9.
10.
11.
12. TOTAL
(sum of lines 8-11)
$ $ $ $
SECTION D - FORECASTED CASH NEEDS
13. Federal
Total for 1st Year 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter
$ $ $ $ $
14. Non-Federal
15. TOTAL
(sum of lines 13 and 14)
$ $ $ $ $
SECTION E - BUDGET ESTIMATES OF FEDERAL FUNDS NEEDED FOR BALANCE OF THE PROJECT
(a) Grant Program FUTURE FUNDING PERIODS (Years)
(b) First (c) Second (d) Third (e) Fourth
16. $ $ $ $
17.
18.
19.
20. TOTAL
(sum of lines 16-19)
$ $ $ $
SECTION F - OTHER BUDGET INFORMATION
21. Direct Charges: 22. Indirect Charges:
23. Remarks:
Authorized for Local Reproduction
Standard Form 424A (Rev. 7-97) Page 2
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INSTRUCTIONS FOR THE SF-424A
Public reporting burden for this collection of information is estimated to average 180 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
information. 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 (0348-0044), Washington, DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET.
SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.
General Instructions
This form is designed so that application can be made for funds
from one or more grant programs. In preparing the budget,
adhere to any existing Federal grantor agency guidelines which
prescribe how and whether budgeted amounts should be
separately shown for different functions or activities within the
program. For some programs, grantor agencies may require
budgets to be separately shown by function or activity. For other
programs, grantor agencies may require a breakdown by function
or activity. Sections A, B, C, and D should include budget
estimates for the whole project except when applying for
assistance which requires Federal authorization in annual or
other funding period increments. In the latter case, Sections A, B,
C, and D should provide the budget for the first budget period
(usually a year) and Section E should present the need for
Federal assistance in the subsequent budget periods. All
applications should contain a breakdown by the object class
categories shown in Lines a-k of Section B.
Section A. Budget Summary Lines 1-4 Columns (a) and (b)
For applications pertaining to a
single
Federal grant program
(Federal Domestic Assistance Catalog number) and
not requiring
a functional or activity breakdown, enter on Line 1 under Column
(a) the Catalog program title and the Catalog number in Column
(b).
For applications pertaining to a
single
program
requiring
budget
amounts by multiple functions or activities, enter the name of
each activity or function on each line in Column (a), and enter the
Catalog number in Column (b). For applications pertaining to
multiple programs where none of the programs require a
breakdown by function or activity, enter the Catalog program title
on each line in
Column
(a) and the respective Catalog number on
each line in Column (b).
For applications pertaining to
multiple
programs where one or
more programs
require
a breakdown by function or activity,
prepare a separate sheet for each program requiring the
breakdown. Additional sheets should be used when one form
does not provide adequate space for all breakdown of data
required. However, when more than one sheet is used, the first
page should provide the summary totals by programs.
Lines 1-4, Columns (c) through (g)
For new applications
, leave Column (c) and (d) blank. For each
line entry in Columns (a) and (b), enter in Columns (e), (f), and
(g) the appropriate amounts of funds needed to support the
project for the first funding period (usually a year).
For continuing grant program applications
, submit these forms
before the end of each funding period as required by the grantor
agency. Enter in Columns (c) and (d) the estimated amounts of
funds which will remain unobligated at the end of the grant
funding period only if the Federal grantor agency instructions
provide for this. Otherwise, leave these columns blank. Enter in
columns (e) and (f) the amounts of funds needed for the
upcoming period. The amount(s) in Column (g) should be the
sum of amounts in Columns (e) and (f).
For supplemental grants and changes
to existing grants, do not
use Columns (c) and (d). Enter in Column (e) the amount of the
increase or decrease of Federal funds and enter in Column (f) the
amount of the increase or decrease of non-Federal funds. In
Column (g) enter the new total budgeted amount (Federal and
non-Federal) which includes the total previous authorized
budgeted amounts plus or minus, as appropriate, the amounts
shown in Columns (e) and (f). The amount(s) in Column (g)
should not equal the sum of amounts in Columns (e) and (f).
Line 5 - Show the totals for all columns used.
Section B Budget Categories
In the column headings (1) through (4), enter the titles of the
same programs, functions, and activities shown on Lines 1-4,
Column (a), Section A. When additional sheets are prepared for
Section A, provide similar column headings on each sheet. For
each program, function or activity, fill in the total requirements for
funds (both Federal and non-Federal) by object class categories.
Line 6a-i - Show the totals of Lines 6a to 6h in each column.
Line 6j - Show the amount of indirect cost.
Line 6k - Enter the total of amounts on Lines 6i and 6j. For all
applications for new grants and continuation grants the total
amount in column (5), Line 6k, should be the same as the total
amount shown in Section A, Column (g), Line 5. For
supplemental grants and changes to grants, the total amount of
the increase or decrease as shown in Columns (1)-(4), Line 6k
should be the same as the sum of the amounts in Section A,
Columns (e) and (f) on Line 5.
Line 7 - Enter the estimated amount of income, if any, expected
to be generated from this project. Do not add or subtract this
amount from the total project amount, Show under the program
SF-424A (Rev. 7-97) Page 3
INSTRUCTIONS FOR THE SF-424A (continued)
narrative statement the nature and source of income. The
estimated amount of program income may be considered by the
Federal grantor agency in determining the total amount of the
grant.
Section C. Non-Federal Resources
Lines 8-11 Enter amounts of non-Federal resources that will be
used on the grant. If in-kind contributions are included, provide a
brief explanation on a separate sheet.
Column (a) - Enter the program titles identical to
Column (a), Section A. A breakdown by function or
activity is not necessary.
Column (b) - Enter the contribution to be made by the
applicant.
Column (c) - Enter the amount of the State’s cash and
in-kind contribution if the applicant is not a State or
State agency. Applicants which are a State or State
agencies should leave this column blank.
Column (d) - Enter the amount of cash and in-kind
contributions to be made from all other sources.
Column (e) - Enter totals of Columns (b), (c), and (d).
Line 12 - Enter the total for each of Columns (b)-(e). The amount
in Column (e) should be equal to the amount on Line 5, Column
(f), Section A.
Section D. Forecasted Cash Needs
Line 13 - Enter the amount of cash needed by quarter from the
grantor agency during the first year.
Line 14 - Enter the amount of cash from all other sources needed
by quarter during the first year.
Line 15 - Enter the totals of amounts on Lines 13 and 14.
Section E. Budget Estimates of Federal Funds Needed for
Balance of the Project
Lines 16-19 - Enter in Column (a) the same grant program titles
shown in Column (a), Section A. A breakdown by function or
activity is not necessary. For new applications and continuation
grant applications, enter in the proper columns amounts of Federal
funds which will be needed to complete the program or project over
the succeeding funding periods (usually in years). This section
need not be completed for revisions (amendments, changes, or
supplements) to funds for the current year of existing grants.
If more than four lines are needed to list the program titles, submit
additional schedules as necessary.
Line 20 - Enter the total for each of the Columns (b)-(e). When
additional schedules are prepared for this Section, annotate
accordingly and show the overall totals on this line.
Section F. Other Budget Information
Line 21 - Use this space to explain amounts for individual direct
object class cost categories that may appear to be out of the
ordinary or to explain the details as required by the Federal grantor
agency.
Line 22 - Enter the type of indirect rate (provisional, predetermined,
final or fixed) that will be in effect during the funding period, the
estimated amount of the base to which the rate is applied, and the
total indirect expense.
Line 23 - Provide any other explanations or comments deemed
necessary.
SF-424A (Rev. 7-97) Page 4
OMB Approval No. 0348-0040
ASSURANCES - NON-CONSTRUCTION PROGRAMS
NOTE:
As the duly authorized representative of the applicant, I certify that the applicant:
Previous Edition Usable Standard Form 424B (Rev. 7-97)
Authorized for Local Reproduction Prescribed by OMB Circular A-102
Public reporting burden for this collection of information is estimated to average 15 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
information. 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 (0348-0040), Washington, DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET.
SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.
Certain of these assurances may not be applicable to your project or program. If you have questions, please contact the
awarding agency. Further, certain Federal awarding agencies may require applicants to certify to additional assurances. If such
is the case, you will be notified.
Has the legal authority to apply for Federal assistance
and the institutional, managerial and financial capability
(including funds sufficient to pay the non-Federal share
of project cost) to ensure proper planning, management
and completion of the project described in this
application.
Will give the awarding agency, the Comptroller General
of the United States and, if appropriate, the State,
through any authorized representative, access to and
the right to examine all records, books, papers, or
documents related to the award; and will establish a
proper accounting system in accordance with generally
accepted accounting standards or agency directives.
Will establish safeguards to prohibit employees from
using their positions for a purpose that constitutes or
presents the appearance of personal or organizational
conflict of interest, or personal gain.
Will initiate and complete the work within the applicable
time frame after receipt of approval of the awarding
agency.
Will comply with the Intergovernmental Personnel Act of
1970 (42 U.S.C. §§4728-4763) relating to prescribed
standards for merit systems for programs funded under
one of the 19 statutes or regulations specified in
Appendix A of OPM's Standards for a Merit System of
Personnel Administration (5 C.F.R. 900, Subpart F).
Will comply with all Federal statutes relating to
nondiscrimination. These include but are not limited to:
(a) Title VI of the Civil Rights Act of 1964 (P.L. 88-352)
which prohibits discrimination on the basis of race, color
or national origin; (b) Title IX of the Education
Amendments of 1972, as amended (20 U.S.C. §§1681-
1683, and 1685-1686), which prohibits discrimination on
the basis of sex; (c) Section 504 of the Rehabilitation
Act of 1973, as amended (29 U.S.C. §794), which
prohibits discrimination on the basis of handicaps; (d)
the Age Discrimination Act of 1975, as amended (42
U.S.C. §§6101-6107), which prohibits discrimination
on the basis of age; (e) the Drug Abuse Office and
Treatment Act of 1972 (P.L. 92-255), as amended,
relating to nondiscrimination on the basis of drug
abuse; (f) the Comprehensive Alcohol Abuse and
Alcoholism Prevention, Treatment and Rehabilitation
Act of 1970 (P.L. 91-616), as amended, relating to
nondiscrimination on the basis of alcohol abuse or
alcoholism; (g) §§523 and 527 of the Public Health
Service Act of 1912 (42 U.S.C. §§290 dd-3 and 290 ee
-
3), as amended, relating to confidentiality of alcohol
and drug abuse patient records; (h) Title VIII of the
Civil Rights Act of 1968 (42 U.S.C. §§3601 et seq.), as
amended, relating to nondiscrimination in the sale,
rental or financing of housing; (i) any other
nondiscrimination provisions in the specific statute(s)
under which application for Federal assistance is being
made; and, (j) the requirements of any other
nondiscrimination statute(s) which may apply to the
application.
Will comply, or has already complied, with the
requirements of Titles II and III of the Uniform
Relocation Assistance and Real Property Acquisition
Policies Act of 1970 (P.L. 91-646) which provide for
fair and equitable treatment of persons displaced or
whose property is acquired as a result of Federal or
federally-assisted programs. These requirements apply
to all interests in real property acquired for project
purposes regardless of Federal participation in
purchases.
Will comply, as applicable, with provisions of the
Hatch Act (5 U.S.C. §§1501-1508 and 7324-7328)
which limit the political activities of employees whose
principal employment activities are funded in whole or
in part with Federal funds.
1.
2.
3.
4.
5.
6.
7.
8.
SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL TITLE
APPLICANT ORGANIZATION DATE SUBMITTED
Standard Form 424B (Rev. 7-97) Back
Will comply, as applicable, with the provisions of the Davis-
Bacon Act (40 U.S.C. §§276a to 276a-7), the Copeland Act
(40 U.S.C. §276c and 18 U.S.C. §874), and the Contract
Work Hours and Safety Standards Act (40 U.S.C. §§327-
333), regarding labor standards for federally-assisted
construction subagreements.
Will comply, if applicable, with flood insurance purchase
requirements of Section 102(a) of the Flood Disaster
Protection Act of 1973 (P.L. 93-234) which requires
recipients in a special flood hazard area to participate in the
program and to purchase flood insurance if the total cost of
insurable construction and acquisition is $10,000 or more.
Will comply with environmental standards which may be
prescribed pursuant to the following: (a) institution of
environmental quality control measures under the National
Environmental Policy Act of 1969 (P.L. 91-190) and
Executive Order (EO) 11514; (b) notification of violating
facilities pursuant to EO 11738; (c) protection of wetlands
pursuant to EO 11990; (d) evaluation of flood hazards in
floodplains in accordance with EO 11988; (e) assurance of
project consistency with the approved State management
program developed under the Coastal Zone Management
Act of 1972 (16 U.S.C. §§1451 et seq.); (f) conformity of
Federal actions to State (Clean Air) Implementation Plans
under Section 176(c) of the Clean Air Act of 1955, as
amended (42 U.S.C. §§7401 et seq.); (g) protection of
underground sources of drinking water under the Safe
Drinking Water Act of 1974, as amended (P.L. 93-523);
and, (h) protection of endangered species under the
Endangered Species Act of 1973, as amended (P.L. 93-
205).
Will comply with the Wild and Scenic Rivers Act of
1968 (16 U.S.C. §§1271 et seq.) related to protecting
components or potential components of the national
wild and scenic rivers system.
Will assist the awarding agency in assuring compliance
with Section 106 of the National Historic Preservation
Act of 1966, as amended (16 U.S.C. §470), EO 11593
(identification and protection of historic properties), and
the Archaeological and Historic Preservation Act of
1974 (16 U.S.C. §§469a-1 et seq.).
Will comply with P.L. 93-348 regarding the protection of
human subjects involved in research, development, and
related activities supported by this award of assistance.
Will comply with the Laboratory Animal Welfare Act of
1966 (P.L. 89-544, as amended, 7 U.S.C. §§2131 et
seq.) pertaining to the care, handling, and treatment of
warm blooded animals held for research, teaching, or
other activities supported by this award of assistance.
Will comply with the Lead-Based Paint Poisoning
Prevention Act (42 U.S.C. §§4801 et seq.) which
prohibits the use of lead-based paint in construction or
rehabilitation of residence structures.
Will cause to be performed the required financial and
compliance audits in accordance with the Single Audit
Act Amendments of 1996 and OMB Circular No. A-133,
"Audits of States, Local Governments, and Non-Profit
Organizations."
Will comply with all applicable requirements of all other
Federal laws, executive orders, regulations, and policies
governing this program.
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xx/xx/2012
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SF 424 Application Package (HHS)

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Completed 24 July 2020

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