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<br />OMS Number: 4040-0004 <br />Expiration Date: 01/31/2009 <br /> <br />Application for Federal Assistance SF-424 <br /> <br />Version 02 <br /> <br />16. Congressional Districts Of: <br />. a. Applicant INDOO <br /> <br />. b. Program/Project l NDOO <br /> <br />~J <br /> <br />Attach an additional list of Program/Project Congressional Districts if needed. <br /> <br />== <br /> <br />-"-l <br /> <br /> <br />I" <br /> <br />lC <br /> <br />17. Proposed Project: <br />. a. Start Date: I09/01/20,,0! _ 1 <br /> <br />. b. End Date: [08/30/20081 <br /> <br />18. Estimated Funding ($): <br /> <br />. a. Federal <br /> <br />[ <br />r <br /> <br />500,000~~1 <br />.?~0,~~0.0~ <br />~~:~.,,'-~~ <br />0.00'1 <br />0.001 <br />o.ool <br />..~~o,~_~O~O] <br /> <br />. b. Applicant <br />. c. State <br /> <br />. g. TOTAL <br /> <br />L <br />l____ <br />I-~~~ ~ <br />I <br />,=- --~-~- -----~ <br /> <br />. d. Local <br /> <br />. e. Other <br /> <br />. f. Program Income <br /> <br />. 19. Is Application Subject to Review By State Under Executive Order 12372 Process? <br /> <br />~ a. This application was made available to the State under the Executive Order 12372 Process for review on l 06/25/200~] . <br /> <br /> <br />b. Program is subject to E.O. 12372 but has not been selected by the State for review. <br /> <br /> <br />o c. Program is not covered by E.O. 12372. <br /> <br />.20. Is the Applicant Delinquent On Any Federal Debt? (If "Yes", provide explanation.) <br /> <br />II Yes <br /> <br />~ No <br /> <br />L____=:J <br /> <br />21. .By signing this application, I certify (1) to the statements contained in the list of certifications.. and (2) that the statements <br />herein are true, complete and accurate to the best of my knowledge. I also provide the required assurances.. and agree to <br />comply with any resulting terms if I accept an award. I am aware that any false, fictitious, or fraudulent statements or claims <br />may subject me to criminal, civil, or administrative penalties. (U.S. Code, Title 218, Section 1001) <br /> <br />~ .. I AGREE <br /> <br />.. The list of certifications and assurances, or an internet site where you may obtain this list, is contained in the announcement or agency <br />specific instructions. <br /> <br />Authorized Representative: <br /> <br />Prefix: <br /> <br />~~~,,_..._.~-- <br />lD." <br /> <br />lEllingsberg <br /> <br />[] <br /> <br />. First Name: ~n <br /> <br />Middle Name: <br /> <br />. Last Name: <br /> <br />Suffix: l <br /> <br />. Title: @o~e~.nment Offi~ial <br />. Telephone Number: 1701-271-2914 <br />. Email: [~IIin"gsber~Ci!Jco:<:ass.~~s. <br /> <br />1 Fax Number: 1701-271-2967 <br /> <br />1 <br /> <br />. Signature of Authorized Representative: I Completed by Grants.goY upon SUbmiSSion.J . Date Signed: ~d by Grants.goY upon submission. <br /> <br />Authorized for Local Reproduction <br /> <br />Standard Form 424 (Revised 10/2005) <br />Prescribed by OMS Circular A-102 <br />