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):
10/17/12
2b. APPLICATION ID:
13SR142857
3. DATE RECEIVED BY STATE:
STATE APPLICATION IDENTIFIER:
4. DATE RECEIVED BY FEDERAL AGENCY:
10/17/12
FEDERAL IDENTIFIER:
13SRWMO010
5. APPLICATION INFORMATION
LEGAL NAME: The Independent Living Center, Inc.
DUNS NUMBER: 795606719
ADDRESS (give street address, city, state, zip code and county):
2639 E. 34th Street
Joplin MO 64804 - 4337
County: Newton
NAME AND CONTACT INFORMATION FOR PROJECT DIRECTOR OR OTHER PERSON TO BE CONTACTED ON MATTERS INVOLVING THIS APPLICATION (give area codes):
NAME: Shelly Goerz
TELEPHONE NUMBER: (417) 659-8086 242
FAX NUMBER: (417) 659-8087
INTERNET E-MAIL ADDRESS: sgoerz@ilcenter.org
6. EMPLOYER IDENTIFICATION NUMBER (EIN):
431714219
7. TYPE OF APPLICANT:
7a. Non-Profit
7b. Service/Civic Organization
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: 94.002
10b. TITLE: Retired and Senior Volunteer Program
11.a. DESCRIPTIVE TITLE OF APPLICANT'S PROJECT:
RSVP of Southwest Missouri
11.b. CNCS PROGRAM INITIATIVE (IF ANY):
12. AREAS AFFECTED BY PROJECT (List Cities, Counties, States, etc):
The counties include Jasper, Newton, McDonald and Barton in southwest Missouri. The main municipalities include: Joplin, Neosho, Webb City, Carthage, and Lamar.
Southwest Missouri RSVP is Missouri Opportunity #11
13. PROPOSED PROJECT: START DATE: 04/01/13 END DATE: 03/31/16
14. CONGRESSIONAL DISTRICT OF:   a.Applicant MO 07   b.Program MO 07
15. ESTIMATED FUNDING: Year #: 1
a. FEDERAL
$ 32,126.00
b. APPLICANT
$ 13,983.00
c. STATE
$ 5,000.00
d. LOCAL
$ 2,500.00
e. OTHER
$ 6,483.00
f. PROGRAM INCOME
$ 0.00
g. TOTAL
$ 46,109.00
16. IS APPLICATION SUBJECT TO REVIEW BY STATE EXECUTIVE ORDER 12372 PROCESS?
XYES. THIS PREAPPLICATION/APPLICATION WAS MADE AVAILABLE TO THE STATE EXECUTIVE ORDER 12372 PROCESS FOR REVIEW ON:
DATE: 09/07/12
NO. 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:
Stephanie Brady
b. TITLE:
Director of Programs
c. TELEPHONE NUMBER:
(417) 659-8086
d. SIGNATURE OF AUTHORIZED REPRESENTATIVE:
e. DATE SIGNED:
10/17/12