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<br /> OMS Number: 4040-0004 <br /> Expiration Date: 01/31/2009 <br />Application for Federal Assistance SF-424 Version 02 <br />16. Congressional Districts Of: <br />* a. Applicant 1 ND-OO I * b. Program/Project 1 ND-OO <br />Attach an additional list of Program/Project Congressional Districts if needed. <br />I I Hi'Add1!i! I II I <br />17. Proposed Project: <br />* a. Start Date: 110/01/2007 I * b. End Date: 107/31/2008 <br />18. Estimated Funding ($): <br />* a. Federal I 78,319,001 <br />* b. Applicant I 0,001 <br />* c. State I 0001 <br />* d. Local I 0.001 <br />* e. Other I 78,319.00 I <br />of. Program Income I 0001 <br />* g. TOTAL I 156,638.001 <br />" 19. Is Application Subject to Review By State Under Executive Order 12372 Process? <br />[{] a. This application was made available to the State under the Executive Order 12372 Process for review on 107/12/2007 I <br />Db Program is subject to E.O, 12372 but has not been selected by the State for review. <br />Dc. Program is not covered by E.O. 12372. <br />" 20. Is the Applicant Delinquent On Any Federal Debt? (If "Ves", provide explanation.) <br />DYes [{] No 1 I <br />21. "By signing this application, I certify (1) to the statements contained in the list of certifications"" and (2) that the tatements <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 />[{] "" I AGREE <br />** The list of certifications and assurances, or an internet site where you may obtain this list, is contained in the announcemer t or agency <br />specific instructions. <br />Authorized Representative: <br />Prefix: IMr, 1 " First Name: IGlenn I <br />Middle Name: 10 1 <br />* Last Name: I Ellingsberg I <br />Suffix: I I <br />* Title: I Government Official I <br />* Telephone Number: 1701-271-2914 1 Fax Number: 1701-271-2967 1 <br />" Email: 1 ellingsberg@co.cass.nd.us 1 <br />* Signature of Authorized Representative: I Completed by Grants.gov upon submission. I * Date Signed: I Completed by Grants.gov up' n submission. I <br />Authorized for Local Reproduction Standa d Form 424 (Revised 10/2005) <br /> Pre cribed by OMS Circular A-102 <br />