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Application for Federal Assistance SF-424
16, Congressional Districts Of:
*a.Applicant — [& *b.ProgramProject [2
Atlach an accitional fist of Program/Project Congressional Districts it needed.
Add Attachment | | |
17. Proposed Project:
*a.StatDate: [7 /o1/z32- *bencDate: [|
48, Estimated Funding ($):
* a. Federal 279%, 087 . 00}
* b Applicant
*¢. Stale
*d. Local
*e, Other
*f Program Income
“9. TOTAL 2, 798,037.0C
* 19. ls Application Subject to Review By State Under Executive Order 12372 Process?
a
Oo a. This applicalion was made available to the State under the Executive Order 12372 Process for review on
Oo 'b. Program is subject to £.0. 12372 but has not been selected by the State for review.
¢. Program is not covered by E.0. 12372.
“20. Is the Applicant Delinquent On Any Federal Debt? (If "Yes," provide explanation in attachment.)
OYes No
If"Yes", provide explanation and attach
21. ‘By signing this application, | 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 | accept an award. !am aware that any false, fictitious, or fraudulent statements or claims. may
subject me ta criminal, clvil, or administrative penalties. (U.S. Code, Title 18, Section 1001)
&] * taGRet
™ Ihe list of cerlifical ors and assuiunces, of un inlerel size where you nay obtain this list, is contained in ta announcement or agency
Spec fic instructions
Authorized Representative:
Prefix: “FirstName; |cyatuia
Middle Name: |
“LestName: |Rohlé
Suliix:
“Tite: Fity Meneges -
“Telephone Number: 157-926 2411 Fax Number:
* mai: it rider nva gow
* Signature of Authorized Representative * Date Signed: Lapfaurs]Jump to an indexed page (37 of 37)