PART I - FACE SHEET

APPLICATION FOR FEDERAL ASSISTANCE
Modified Standard Form424 (Rev.02/07 to confirm to the Corporation's eGrants System)
1. TYPE OF SUBMISSION:
Application X Non-construction
2a. DATE SUBMITTED TO CORPORATION FOR NATIONAL AND COMMUNITY SERVICE (CNCS):
2b. APPLICATION ID:
11AC123043
3. DATE RECEIVED BY STATE:
01/19/11
STATE APPLICATION IDENTIFIER:
4. DATE RECEIVED BY FEDERAL AGENCY:
FEDERAL IDENTIFIER:
09ACHIN0010004
5. APPLICATION INFORMATION
LEGAL NAME: Boys & Girls Clubs of Wayne County Indiana, Inc
DUNS NUMBER: 128140829
ADDRESS (give street address, city, state, zip code and county):
1717 South L Street
Richmond IN 47374 - 7400
County: Wayne
NAME AND CONTACT INFORMATION FOR PROJECT DIRECTOR OR OTHER PERSON TO BE CONTACTED ON MATTERS INVOLVING THIS APPLICATION (give area codes):
NAME: Lana Taylor
TELEPHONE NUMBER: (317) 356-2308
FAX NUMBER: (317) 356-2320
INTERNET E-MAIL ADDRESS: ltaylor@indianabgc.org
6. EMPLOYER IDENTIFICATION NUMBER (EIN):
351065715
7. TYPE OF APPLICANT:
7a. Non-Profit
7b. Community-Based Organization
8. TYPE OF APPLICATION (Check appropriate box).
XNEW NEW/PREVIOUS GRANTEE
CONTINUATION AMENDMENT
If Amendment, enter appropriate letter(s) in box(es):
A. AUGMENTATION B. BUDGET REVISION
C. NOCOST EXTENSION D. OTHER (specify below):
9. NAME OF FEDERAL AGENCY:
Corporation for National and Community Service
10a. CATALOG OF FEDERAL DOMESTIC ASSISTANCE NUMBER: 94.006
10b. TITLE: AmeriCorps State
11.a. DESCRIPTIVE TITLE OF APPLICANT'S PROJECT:
Project: ACES
11.b. CNCS PROGRAM INITIATIVE (IF ANY):
12. AREAS AFFECTED BY PROJECT (List Cities, Counties, States, etc):
State: IN
Counties: Adams, IN; Allen, IN; Bartholomew,IN; Boone, IN; Clark, IN; Clinton, IN; Delaware, IN; Elkhart, IN; Floyd, IN; Grant, IN; Hancock, IN; Hamilton, IN; Harrison, IN; Huntington, IN; Jackson, IN; Jefferson, IN; Johnson, IN; Kosciusko, IN; Lake, IN; LaPorte, IN; Lawrence, IN; Marion, IN; Marshall, IN; Monroe, IN; Montgomery, IN...
13. PROPOSED PROJECT: START DATE: 09/01/11 END DATE: 08/31/12
14. CONGRESSIONAL DISTRICT OF:   a.Applicant IN 06   b.Program IN 06
15. ESTIMATED FUNDING: Year #: 1
a. FEDERAL
$ 559,284.00
b. APPLICANT
$ 408,290.00
c. STATE
$ 0.00
d. LOCAL
$ 0.00
e. OTHER
$ 0.00
f. PROGRAM INCOME
$ 0.00
g. TOTAL
$ 967,574.00
16. IS APPLICATION SUBJECT TO REVIEW BY STATE EXECUTIVE ORDER 12372 PROCESS?
YES. THIS PREAPPLICATION/APPLICATION WAS MADE AVAILABLE TO THE STATE EXECUTIVE ORDER 12372 PROCESS FOR REVIEW ON:
DATE:
XNO. PROGRAM IS NOT COVERED BY E.O. 12372
17. IS THE APPLICANT DELINQUENT ON ANY FEDERAL DEBT?
YES if "Yes," attach an explanation. XNO
18. TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL DATA IN THIS APPLICATION/PREAPPLICATION ARE TRUE AND CORRECT, THE DOCUMENT HAS BEEN DULY AUTHORIZED BY THE GOVERNING BODY OF THE APPLICANT AND THE APPLICANT WILL COMPLY WITH THE ATTACHED ASSURANCES IF THE ASSISTANCE IS AWARDED.
a. TYPED NAME OF AUTHORIZED REPRESENTATIVE:
Lana Taylor
b. TITLE:
State Director
c. TELEPHONE NUMBER:
(317) 356-2308
d. SIGNATURE OF AUTHORIZED REPRESENTATIVE:
e. DATE SIGNED:
08/10/11