Application for State Grant Assistance

Application for State Grant Assistance
Please note: You will be required to attach the following documents in order to submit a complete application, so please be sure to have these readily available:
- DCEO Mandatory Disclosure
- DCEO Conflict of Interest Disclosure
- Budget
- Narrative (There is no template for this. You will create your own document. There is no limit on number of pages, spacing, font, etc...)
Below are additional documents for reference:
- Wet Lab Capital Program Overview
- Bondability Guidelines
Should you have questions about this, please submit them here.

**Upon submission of this application, a confirmation email will be sent to the applicant via the email address entered for business/administrative office matters below.**
NOFO
Type of Submission
Type of Application
Name of Awarding State Agency
Catalog of State Financial Assistance (CSFA) Number
CSFA Title
Catalog of Federal Domestic Assistance (CFDA)

Not Applicable (No federal funding)
CFDA Number
CFDA Title
CFDA Number
CFDA Title
Additional CFDA Number, if required
Additional CFDA Title, if required
Funding Opportunity Number
Funding Opportunity Title
Competition Identification

Not Applicable
Competition Identification Number
Competition Identification Title
Applicant Information
Legal Name (Name used for DUNS registration and grantee pre-qualification)*
Common Name (DBA)*
Are you using an Employer Identification Number (EIN) or Taxpayer Identification Number (TIN)?*

EINTIN
Employer Identification Number
Taxpayer Identification Number
Organizational DUNS Number*
SAM Cage Code*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Applicant's Organizational Unit
Department Name*
Division Name*
Applicant's Name and Contact Information for Person to be Contacted for Program Matters involving this Application.
Name*

First NameMiddle NameLast NameSuffix
Title*
Organizational Affiliation*
Phone Number*

Area CodePhone Number
Fax Number

Area CodePhone Number
Email Address*
example@example.com (Please note: This email will not be the one to receive the confirmation email upon submission. The next email entry will be.)
Applicant's Name and Contact Information for Person to be Contacted for Business/Administrative Office Matters involving this Application.
Name*

First NameMiddle NameLast NameSuffix
Title*
Organizational Affiliation*
Phone Number*

Area CodePhone Number
Fax Number

Area CodePhone Number
Email Address*
example@example.com (This email will be the one to receive the confirmation of application upon submission.)
Areas Affected
Cities Affected by the Project (select all that apply)*
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Counties Affected by the Project (select all that apply)*
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Attachments for Areas Affected by the Project (maps)*

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Legislative Districts of APPLICANT (select all that apply)*
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Congressional Districts of APPLICANT (select all that apply)*
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Legislative Districts of PROJECT (select all that apply)*
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Congressional Districts of PROJECT (select all that apply)*
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Applicant's Project
Description Title of Applicant's Project*
Proposed Project Term
Start Date*

MonthDayYear
Date
End Date*

MonthDayYear
Date
Estimated Funding (Include all that apply)
Amount Requested from the State*
Applicant Contribution (e.g. in kind, matching)*
Local Contribution*
Other Source of Contribution*
Program Income*
Total Amount
Total Match
Percentage Match
At least 1:1 match?

YesNo
Documents
Please upload the Narrative referenced above.*

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Please upload the DCEO Mandatory Disclosure Form referenced above.*

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Please upload the DCEO Conflict of Interest Disclosure Form referenced above.*

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Please upload the Budget Template referenced above.*

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Applicant Certification:

By signing this application, I 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 I accept an award. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil or administrative penalties. (U.S. Code, Title 18, Section 1001)

(*) The list of certification and assurances, or an internet site where you may obtain this list is contained in the Notice of Funding Opportunity. If a NOFO was not required for the award, the state agency will specify required assurances and certifications as an addendum to the application.
Authorized Representative
Name*

First NameMiddle NameLast NameSuffix
Title*
Organizational Affiliation*
Phone Number*

Area CodePhone Number
Fax Number

Area CodePhone Number
Email Address*
example@example.com
Signature of Authorized Representative*

Clear
Date Signed*

MonthDayYear
DateHourMinutesAM/PM Option
Should be Empty: