BLM Revenue Folder BLM HEF051M10

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INSTRUCTIONS FOR THE SF-424 Public reporting burden for this collection of information is estimated to average 45 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 staridacd 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 have 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, 1 ~ ~counties, cities). 2.• Date application submitted to Federal agency (or State if applicable) and 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, 15. Amount requested or to be contributed during the first leave blank. - funding/budget period by each contributor. Value of in- kind contributions should be included on.appropriate 5. Legal name of applicant, name of primary organizational, unit lines as applicable. If the action will result in a dollar which will undertake the assistance activity, complete address of change to an existing award, indicate only the amount the applicant, and name and telephone number of the person to of the change. For decreases, enclose the amounts in contact on matters related to this application. parentheses. If both basic and supplemental amounts • are included, show breakdown on an attached sheet. 6. Enter Employer Identification Number (EIN) as assigned by the For multiple program funding, use totals and show breakdown usin same cate ories as item 15. Internal Revenue Service: g g 7. Enter the appropriate letter in the space provided. 16. Applicants should contact the State Single Point of . - ~ Contact (SPOC) for Federal Executive Order 12372 to 8. Check appropriate box and enter appropriate letter(s) in the determine whether the application is subject to the space(s) provided: State intergovernmental review process. I~, "New" means a new assistance award. 17. This question applies to the applicant organization, not . the persomwho signs as the authorized representative. - "Continuation" means an extension for an additional Categories of debt include delinquent audit funding/budget period for a project with a projected disallowances, loans and taxes. • completion date. _ 18. To be signed by the authorized representative of the - "Revision" means any change in the Federal applicant. A copy of the governing body's Government's financial obligation or contingent authorization for you to sign this application as official liability from an existing obligation. representative must be on file in the applicant's office. {Certain Federal agencies may require that this 9. Name of Federal agency from which assistance is being authorization be submitted as part of the application.) requested with this application. 10. Use the Catalog of Federal Domestic Assistance number and • - title of the program under which assistance is requested. 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 SF-424 (Rev. 7-97) Back • description of this project.