217.782.7500 Springfield | 312.814.7179 Chicago | www.illinois.gov/dceo
Uniform Application for State Grant Assistance
1. Type of Submission
Changed / Corrected Application
2. Type of Application
Continuation (i.e. multiple year grant)
Revision (modification to initial application)
3. Name of Awarding State Agency Illinois Department of Commerce & Economic Opportunity
4. Catalog of State Financial Assistance (CSFA) Number
5. CS
FA Title
Catalog of Federal Domestic Assistance (CFDA)
Not Applicable (No federal funding)
6. CFDA Number
7. CF
DA Title
8. CF
DA Number
9. CFDA Title
Additional CFDA
Number, if required
Additional CFDA
Title, if required
Funding Opportunity Information
10. Funding Opportunity Number
11. Funding Opportunity Title
217.782.7500 Springfield | 312.814.7179 Chicago | www.illinois.gov/dceo
Applicant Information
12. Legal Name (Name used for DUNS
registration and grantee pre-qualification)
13. Common Name (DBA)
14. Employer/Taxpayer identification
number (EIN, TIN)
15. Organizational DUNS Number
16. SAM Cage Code
17. Business Address
(Address 1)
(Address 2)
(City), (State), (zip - 4)
18. Telephone Number
Applicant's Organizational Unit
19. Department Name
20. Division Name
Applicant's Name and Contact Information for Person to be Contacted for Program Matters involving this
21. First Name
22. Last Name
23. Suffix
24. T
25. Or
ganizational Affiliation
26. Te
lephone Number
27. E-mail Address
217.782.7500 Springfield | 312.814.7179 Chicago | www.illinois.gov/dceo
Applicant's Name and Contact Information for Person to be Contacted for Business/Administrative Office
Matters involving the Application.
28. First N
29. Last Name
30. Suffix
31. Title
32. Organi
zational Affiliation
33. Telephone Number
34. E-mail Address
Areas Affected
35. Areas Affected by the Project (cities,
counties, state-wide, add attachments
e.g. maps)
36. State Senate District and Senator’s
Name for Project
37. State Representative District and
Representative’s Name for Project
Applicant's Project
38. Description Title of
Applicant's Project
39. Proposed Project Term
Start Date
End Date
217.782.7500 Springfield | 312.814.7179 Chicago | www.illinois.gov/dceo
40. 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
Total Amount
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 18, 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 Opportunity. If a NOFO was not required for the award, the state agency
will specify required assurances and certifications as an addendum to the application.
Authorized Representat
ive (Chief Elected Official)
41. First Name
42. Last Name
43. Suffix
44. Title
45. Telephone Number
46. E-mail Address
Signature of Authorized Representative
Date Signed
I Agree