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2. APPLE L NUMBER

3. STATE NUMBER
FEDERAL ASSISTANCE CANTS

APPLE
APPLE

CATION 1. TYPE

CATION

IDENTI OF

IDENTE

FIER
NOTICE OF INTENT (OPTIONAL)

b. DATE SUBMISSION

FIER

b. DATE

NOTE: TO BE
Your month day

ASSIGNED

Year manche day (Mark op PREAPPLICATION

ASSIGNED propriate

BY STATE
APPLICATION
10

10 bax)

Lane

Blank 4. LEGAL APPLICANT/RECIPIENT

6. EMPLOYEA IDENTIFICATION NUMBER (EIN) e Applicant Namo b. Organization Unit

PRO c. Stroot/P.O. Box

NUMBER

GRAM d. City

o. County 1. State

(From CFDA) ZIP Code.

MULTIPLE O

b. TITLE h. Contact Person (Name

& Telephone Na)
7. TITLE OF APPLICANTS PAQJECT (UDO section of this form to provide a summary description of the 6. TYPE OF APPLICANT/RECIPIENT
project)

Special PupouDieta

Community Action Agency
Cle

Higher Education inton
Orgontention

Anom Treo
o con

koner (Special Flohool Oute

Enter appropriate lerver

SECTION APPLICANT/RECIPIENT DATA

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SECTION INCERTIFICATION

Yes

No 22.

To the best of my knowledge and boliol. a YES, THIS NOTICE OF INTENT/PREAPPLICATION/APPLICATION WAS MADE AVAILABLE TO THE STATE THE

data in this proapplication/application EXECUTIVE ORDER 12372 PROCESS FOR REVIEW ON:
APPLICANT wo true and correct, the document has DATE
CERTIFIES boon duty authorized by the governing
THAT body of the applicant and the applicant

will comply with the attached assurancea D. NO, PROGRAM IS NOT COVERED BY E.O. 12372 0
if the assistance is approved.

OR PROGRAM HAS NOT BEEN SELECTED BY STATE FOR REVIEW O
23.
TYPED NAME AND TITLE

b. SIGNATURE CERTIFYING REPRE SENTATIVE 24. APPLICA Year month day

25. FEDERAL APPLICATION IDENTIFICATION NUMBER 26. FEDERAL GRANT IDENTIFICATION TION

RECEIVED 19 27. ACTION TAKEN

20.
FUNDING

Year month day

30.

Yaar month date

STARTING OL AWARDED

29. ACTION DATE

19

DATE 19 O b. REJECTED 1. FEDERAL .00 31. CONTACT FOR ADDITIONAL INFORMA 32.

Year month date O C. RETURNED FOR

TION (Name and telephone number)

ENDING
AMENDMENT
b. APPLICANT
.00

DATE

19 O d. RETURNED FOR E.O. 12372 SUBMISSION C. STATE .00

33. REMARKS ADDED BY APPLICANT TO 6. LOCAL

.00 STATE O .. DEFERRED 0. OTHER

.00 O 1. WITHORAWN f. TOTAL .00

Yos

MO

SECTION 1 FEDERAL

AGENCY ACTION

O No

124-103

NSN 7540_01-008-8162
PREVIOUS EDITION
IS NOT USABLE

STANDARD FORM 424 PAGE 1-(Rov. 4-84)
Prescribed by OMB Circular d-103

This is a standard form used by applicants as a required facesheet for preapplications and applications submitted in accordance with OMB Circular A-102. 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.

APPLICANT PROCEDURES FOR SECTIONI

Applicant will complete all items in Section I with the exception of Box 3. "State Application Identifier." If an item is not applicable, wrho "NA" Nadditional space is needed, insert an asterisk "* " and use Section I. An explanation follows for each ler: Morn

Hem 1. Mark appropriate box. Preapplication and application are described in

(a revision or augmentation under item 14), indicate only the amount of OMB Circular A-102 and Federal agency program instructions. Use of

the change. For decreases, enclose the amount in parentheses. I both this form as a Notice of Intent is at State option. Federal agencies do

basic and supplemental amounts are included, breakout in Section N. not require Notices of Intent.

For multiple program funding, use totals and show program breakouts

in Section iv. 122- amount requested from Federal Government 2a. Applicant's own control number, if desirod.

126— amount applicant will contribute. 120 amount from Stato, it 2b. Date Section I is preparod (at applicant's option).

applicant is not a State. 120, amount from local government, i 3a. Number assigned by State.

applicant is not a local government. 126 amount from any other

sources, explain in Soction N. 3b. Date assigned by State.

136. The district(s) where most of action work will be accomplished. I city 48 4h. Legal name of applicant, name of primary organizational unit which will

wide or State-wide, covering several districts, witte "chy-wide" or undertake the assistance activity, complete address of applicant, and

"State-wide." name and telephone number of the person who can provide further

14. information about this request.

A. Now. A submittal for project not previously funded. 5. Employer Identification Number (EIN) of applicant as assignod by the

B. Renewal. An extension for an additional funding/budget period for a Internal Revenue Service.

project having no projected completion date, but for which Foderal

support must be renewed each year. Ga. Use Catalog of Federal Domestic Assistance (CFDA) number assigned to program under which assistance is requested. W more than one

C. Revision. A modification to project nature or scope which may result program (e.g., joint funding). check "multiples and explain in Soction

in funding change (increase or decreaso). IV. If unknown, cite Public Law or U.S. Code.

D. Continuation. An extension for an additional funding/budget period 66. Program title from CFDA. Abbreviate if necessary.

for a project with a projected completion date. 7. Use Soction I to provide a summary description of the project. I

E. Augmentation. A requirement for additional funds for a project appropriate, i.e., if project aftects particular shos as, for example,

previously awarded funds in the same tunding/budget period. construction or real property projects, attach a map showing the

Project nature and scope unchanged. project location.

15. Approximate date project expected to begin (usually associated with 8. "City" includes town, township or other municipality.

estimated date of avai ility of funding). 9. List only largest unit or units affected, such as State, county, or city. 16. Estimated number of months to completo project aner Federal funds

aro available. 10. Estimated number of persons directly benefiting from project. 11. Chock the type(s) of assistance requested.

17. Complete only for revisions (tom 14c), or augmentations (horn 140). A. Basic Grant an original request for Foderal funds.

18. Date preapplication/application must be submitted to Federal agency B. Supplemental Grant a request to increase a basic grant in certain

in order to be eligible for funding consideration. cases where the eligible applicant cannot supply the required 19. Name and address of the Federal agency 10 which this request to matching share of the basic Federal program (0.9.. grants awarded

addressed. Indicate as clearly as possible the name of the office to by the Appalachian Regional Commission to provide the applicant

which the application will be delivered. a matching share).

20. Existing Foderal grant identification number if this is not a new request E. Other. Explain in Section N.

and directly relates to a previous Foderal action. Otherwise, writo 12. Amount requested or to be contributed during the first funding/budget

"NA." period by each contributor. Value of in-kind contributions should be 21. Check appropriate box as to whether Section N of form contains included. If the action is a change in dollar amount of an existing grant

remarks and/or additional remarks are attached.

APPLICANT PROCEDURES FOR SECTION II

Applicants will always complete either Item 22a or 22b and items 23a and 236. 22a. Complete if application is subject to Executive Order 12372 (State 22b. review and comment).

23a.

Check if application is not subject to E.O. 12372.
Name and title of authorized representative of logal applicant.

FEDERAL AGENCY PROCEDURES FOR SECTION 1

26.

27.

28.

Applicant completes only Sections I and II. Section III is completed by Federal agencios.
Uso to identity award actions.

will contribute. 28c-amount from Staro, if applicant is not a State.

28camount from local government, it applicant is not a local govern Use Section N to amplity where appropriate.

ment. 280- amount from any other sources, explain in Soction N. Amount to be contributed during the first funding/budget period by

29. Date action was taken on this request. each contributor. Value of in-kind contributions will be included. If the

30. Date funds will become available. action is a change in dollar amount of an existing grant (a rovision or

31. augmentation under Item 14), indicate only the amount of change. For

Name and telephone number of agency person who can provide more decreases, enclose the amount in parentheses. N both basic and

information regarding this assistance.

32. supplemental amounts are included, breakout in Section IV. For multiple

Date after which funds will no longer be available for obligation. program funding, use totals and show program breakouts in Section IV. 33. Check appropriate box as to whether Section N of form contains 28a_amount awarded by Federal Government. 286 amount applicant

Federal remarks and/or attachment of additional remarks....

☆ GPO : 1984 O 461-275 (277)

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(5-85)

U.S. Dapartment of Energy

Assurance of Compliance

· Nondlecrimination in Fodorally Anslated Programa

- (Horoinahor callod the "Applicant'') HEREBY AGREES to comply with Title VI of the Civil Rights Act of 1984 (Pub. L. 88-352), Section 16 of the Federal Energy Administration Act of 1974 (Pub. L. 93-275). Section 101 of tho Enorgy Reorganization Act of 1974 (Pub. L. 93-438). Tito IX of the Education Amondmonis of 1972, us amondod, (Pub. L. 92-318, Pub. L. 93-568. and Pub. L. 94432). Section 504 of the Ronabilitation Act of 1973 (Pub. L. 93-112), the Age Discrimination Act of 1975 (Pub. L. 94-135). Title VIII of the Civil Righta Act of 1963 (Pub. L. 90-284), the Depanmont of Energy Organization Act of 1977 (Pub. L. 95-01), and the Energy Conservation and Pro duction Act of 1976, as amendod. (Pub. L. 94.385). In accordanco with the above laws and regulations issued pursuant thoroto, the Applicant agrees to assure that no porson in the United States shall, on the ground of race, color, national origin, sox, ago. or handicap, bo excludod from participation in, bo doniod the benefits of, or bo otherwise subjected to discrimination under any program or activity in which the Applicant rocoivos Fodoral ussistance from the Department of

Energy.

Applicability and
Period of Obligation

In the case of any servico, financial aid, covorod employment, oquipment, property, or structure provided, lousod, or improve

with Fodoral assistance oxtondod to the Applicant by the Deparment of Enorgy, this usurance obligatos the Applicant for the period during which Fodoral assistanco is extonded. In the case of any transtor of such service, financial aid, aguio mont. proporty, or structuro, this assurance obligatos tho transtorno for the period during which Foderal assistance is en tonded. If any personal property is so provided, this assuranco obligatos tho Applicant for the period during which he retains ownorship or possession of the property. In all other casos, this ussuranco obligates the Applicant for the period during which the Foderal ussistanco is extended to the Applicant by the Department of Energy.

Employment Practicao

Whoro pnmary objective of the Foderal assistanco is to provido employmont or whoro the Applicant's omploymont prac. ticos attect the delivery of services in programs or activities resulting from Fodoral ussistance oxtonded by the Departmont, the Applicant agroos not to discriminato on the ground of race, color, national origin, sex, age, or handicap. in its employ mont practices. Such employment practicos may include, but are not limited to, recruitment, recruitment advertising, hiring. layon or formination, promotion, domotion, transfor, rates of pay, training and panicipation in upward mobility programs; or other forms of componuation and use of facilities.

Subrecipient Assurance

The Applicant shall require any individual, organization, or other entity with whom it subcontracts, subgrants, or sublouses for the purpose of providing any servico, financial aid, oquipment, propony, or structuro to comply with laws cited above. To this ond, the subrecipient shall be required to sign a written assuranco torm, however, the obligation of both recipient and subrecipient to ensure compliance is not rolioved by the collection or submission of writton ussurance forms.

Data Collection and
Accow to Records

The Applicant agnos to compile and maintain intormation portaining to programs or activitios doveloped us a noun of the Applicant's recoipi of Fodoral assistance from the Deparment of Energy. Such information shall includo, but is not limited to the following: (1) the manner in which services aro or will be provided and rolated data nocousary for determining whether

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