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:
11AC124276
3. DATE RECEIVED BY STATE:
07/01/11
STATE APPLICATION IDENTIFIER:
602021487
4. DATE RECEIVED BY FEDERAL AGENCY:
FEDERAL IDENTIFIER:
09ACHNH0010002
5. APPLICATION INFORMATION
LEGAL NAME: NH Coalition Against Domestic and Sexual Violence
DUNS NUMBER: 602021487
ADDRESS (give street address, city, state, zip code and county):
PO Box 353
4 S State St.
Concord NH 03302 - 0353
County: Merrimack
NAME AND CONTACT INFORMATION FOR PROJECT DIRECTOR OR OTHER PERSON TO BE CONTACTED ON MATTERS INVOLVING THIS APPLICATION (give area codes):
NAME: Meg K. Dugan
TELEPHONE NUMBER: (603) 224-6466
FAX NUMBER: (603) 224-4666
INTERNET E-MAIL ADDRESS: meg@avap1.org
6. EMPLOYER IDENTIFICATION NUMBER (EIN):
020360151
7. TYPE OF APPLICANT:
7a. Non-Profit
7b. Service/Civic Organization
Community-Based Organization
Statewide Association
Volunteer Management 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:
AmeriCorps Victim Assistance Program
11.b. CNCS PROGRAM INITIATIVE (IF ANY):
12. AREAS AFFECTED BY PROJECT (List Cities, Counties, States, etc):
Throughout New Hampshire.
13. PROPOSED PROJECT: START DATE: 09/06/11 END DATE: 09/02/12
14. CONGRESSIONAL DISTRICT OF:   a.Applicant NH 02   b.Program NH 02
15. ESTIMATED FUNDING: Year #: 1
a. FEDERAL
$ 350,688.00
b. APPLICANT
$ 301,985.00
c. STATE
$ 0.00
d. LOCAL
$ 0.00
e. OTHER
$ 0.00
f. PROGRAM INCOME
$ 0.00
g. TOTAL
$ 652,673.00
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:
Meg K. Dugan
b. TITLE:
Program Director
c. TELEPHONE NUMBER:
(603) 224-6466
d. SIGNATURE OF AUTHORIZED REPRESENTATIVE:
e. DATE SIGNED:
08/24/11