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This is a standard form used by applicants as a required facesheet for preapplications and applications submitted for Federal assistance. It will be used by Federal agencies to obtain applicant certification that States which ave established a review and comment procedure in response to Executive Order 12372 and have selected the program to be included in their process, have been given an opportunity to review the applicant's submission.

Item: Entry: Item: Entry:
1. Self-explanatory. 12. List only the largest political entities affected (e.g., State, counties, cities.
2. Date application submitted to Federal agency (or State if applicable) & applicant's control number (if applicable). 13. Self-explanatory.
3. State use only (if applicable) 14. List the applicant's Congressional District and any District(s) affected by the program or project.
4. If this application is to continue or revise an existing award, enter present Federal identifier number. If for a new project, leave blank. 15. 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. If both basic and supplemental amounts are included, show breakdown on an attached sheet. For multiple program funding, use totals and show breakdown using same categories as item 15.
5. Legal name of applicant, name of primary organizational unit which will undertake this assistance activity, complete address of the applicant, and name and telephone number of the person to contact on matters related to this application. 16. 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.
6. Enter Employer Identification Number (EIN) as assigned by the Internal Revenue Service. 17. 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.
7. Enter the appropriate letter in the space provided. 18. To be signed by the authorized representative of the applicant. A copy of the governing body's authorization for you to sign this application as 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.)
8. Check appropriate box and enter appropriate letter(s) in the space(s) provided.
  • "New" means a new assistance award.
  • "Continuation" means an extension for an additional funding/budget period for a project with a projected completion date.
  • "Revision" means any change in the Federal Government's financial obligation or contingent liability from an existing obligation.
9. Name of Federal agency from which assistance is being requested with this application.    
10. Use the Catalog of Federal Domestic Assistance number and title of the program under which assistance is required.    
11. Enter a brief descriptive title of the project. If more than one program is involved, you should append an explanation on a separate sheet. If appropriate (e.g., construction or real property projects), attach a map showing project location. For preapplications, use a separate sheet to provide a summary description of the project.