Agency Completed Section
4. Name of the Awarding State Agency:
1. Type of Submission: Pre-application Application Change/Corrected Application
New Continuation (i.e. multiple year grant) Revision (modification to initial application)2. Type of Application:
Date Received by State: Time Received by State:
3. Completed by State Agency upon Receipt of Application
5. Catalog of State Financial Assistance (CSFA) Number:
6. CSFA Title:
Catalog of Federal Domestic Assistance (CFDA)
Not Applicable
7. CFDA Number:
8. CFDA Title:
10. CFDA Title:
9. CFDA Number:
Funding Opportunity Information
13. Funding Opportunity Program Field:
12. Funding Opportunity Title:
11. Funding Opportunity Number:
Funding Opportunity Information
15. Competition Identification Title:
14. Competition Identification Number:
Not Applicable
Department of Human Services, Division of Family and Community Services
Special Education-Grants for Infants and Families Early Intervention-Child and Family Connections
Applicant Completed Section
Applicant Information
16. Legal Name (Name used for Data Universal Number System (DUNS) registration and grantee pre-qualification):
17. Common Name (Doing Business As-DBA):
18. Employer/Taxpayer Identification Number (EIN, TIN):
19, Organizational Data Universal Number System (DUNS) Number:
20. Federal System for Award Management Commercial And Government Entity Code (SAM Cage Code):
21. Business Address:
City: State: County: Zip+4:
Applicant's Organization Unit
22. Department Name:
23. Division Name:
Applicant's Name and Contact Information for Person to be Contacted for Program Matters involving this Application
24. First Name: 25. Last Name: 26. Suffix:
27. Title:
28: Organizational Affiliation:
29: Telephone Number: 30. Fax Number:
31. E-mail Address:
Applicant's Name and Contact Information for Person to be Contacted for Business/Administrative Office
Matters involving this Application
32. First Name: 33. Last Name: 34. Suffix:
35. Title:
36: Organizational Affiliation:
37: Telephone Number: 38. Fax Number:
39. E-mail Address:
Areas Affected
40. Areas Affected by the Project (cities, counties, state-wide):
41. Legislative and Congressional Districts of Applicant:
42. Legislative and Congressional Districts of Program/Project:
Applicant's Project
43. Description Title of Applicant's Project (Text only for the Title of the Applicant's Project):
44. Proposed Project Term:
Start Date: End Date:
45. Estimated Funding (include all that apply):
Amount Requested from the State:
Applicant Contribution (e.g., in kind, matching):
Local Contribution:
Other Source of Contribution:
Program Income:
Applicant Certification:
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 certification and assurances, or an internet site where you may obtain this list is contained in the Notice of Funding
I Agree
Authorized Representative
46. First Name: 47. Last Name: 48. Suffix:
49. Title:
50: Telephone Number: 51. Fax Number:
52. E-mail Address:
53. Signature of Authorized Representative: Date Signed:
July 1, 2020
June 30, 2021