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HomeMy WebLinkAboutC21-307 SF-424 waiver of non-federal fundsDocuSign Envelope ID: 310D37F7-BE51-4DE2-B9B2-AB327CBE56E4 OMB Number: 4040-0004 Expiration Date: 10/31/2019 Application for Federal Assistance SF-424 * 1. Type of Submission: Preapplication 0 Application Changed/Corrected Application 2. Type of Application: * If Revision, select appropriate letter(s): New other ❑ Continuation *Other (Specify): ❑X Revision Budget Revision * 3. Date Received: 4. Applicant Identifier: 08CH011349 5a. Federal Entity Identifier: 5b. Federal Award Identifier: 08CH011349 N/A State Use Only: 6. Date Received by State: 7. State Application Identifier: 8. APPLICANT INFORMATION: a. Legal Name: Eagle County Department of Human Services * b. Employer/Taxpayer Identification Number (EIN/TIN): * c. Organizational DUNS: 084024447 846000762 d. Address: * Street1: 551 Broadway Street2: PO Box 660 * City: County/Parish: Eagle Eagle County * State: C0: Colorado Province: * Country: USA: UNITED STATES * Zip / Postal Code: 81631 e. Organizational Unit: Department Name: Division Name: Child, Family & Adult Services Human Services f. Name and contact information of person to be contacted on matters involving this application: Prefix: Mrs. First Name: Middle Name: Kendra * Last Name: Kleinschmidt Suffix: Title: Deputy Director Organizational Affiliation: Eagle County Department of Human Services * Telephone Number: (970) 328-8827 Fax Number: *Email: kendra.kleinschmidt@eaglecounty.us C21-307 DocuSign Envelope ID: 310D37F7-BE51-4DE2-B9B2-AB327CBE56E4 Application for Federal Assistance SF-424 * 9. Type of Applicant 1: Select Applicant Type: County Government Type of Applicant 2: Select Applicant Type: Type of Applicant 3: Select Applicant Type: * Other (specify): * 10. Name of Federal Agency: ACF-Head Start 11. Catalog of Federal Domestic Assistance Number: 93.600 CFDA Title: Head Start * 12. Funding Opportunity Number: eGrants-N/A * Title: N/A 13. Competition Identification Number: Not Applicable Title: Not Applicable 14. Areas Affected by Project (Cities, Counties, States, etc.): Eagle County, Colorado * 15. Descriptive Title of Applicant's Project: Early Head Start Waiver of a portion of the non-federal share requirement Attach supporting documents as specified in agency instructions. C21-307 DocuSign Envelope ID: 310D37F7-BE51-4DE2-B9B2-AB327CBE56E4 Application for Federal Assistance SF-424 16. Congressional Districts Of: * a. Applicant CO-003 b. Program/Project CO-003 Attach an additional list of Program/Project Congressional Districts if needed. 17. Proposed Project: * a. Start Date: 01/01/2021 ' b. End Date: 12/31/2021 18. Estimated Funding ($): * a. Federal 0 * b. Applicant -150, 000 * c. State d. Local e. Other 0 f. Program Income *g.TOTAL-150,000 * 19. Is Application Subject to Review By State Under Executive Order 12372 Process? ❑ a. This application was made available to the State under the Executive Order 12372 Process for review on ❑ b. Program is subject to E.O. 12372 but has not been selected by the State for review. ❑X c. Program is not covered by E.O. 12372. * 20. Is the Applicant Delinquent On Any Federal Debt? (If "Yes," provide explanation in attachment.) ❑ Yes X� No If "Yes", provide explanation and attach 21. *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 218, Section 1001) ® **IAGREE ** The list of certifications and assurances, or an internet site where you may obtain this list, is contained in the announcement or agency specific instructions. Authorized Representative: Prefix: Mr, * First Name: Matt Middle Name: * Last Name: Scherr Suffix: * Title: Chair, Board of County Commissioners * Telephone Number: (970) 328-8605 Fax Number: *Email: Matt.Scherr@eaglecounty.us * Signature of Authorized Representative: jf�* Date Signed: `81 E7B2D718E0473... C21-307