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Application for Federal Assistance SF-424 16. Congressional Districts Of: * a. Applicant 10 ' b. Program /Project 10 Attach an additional list of Program /Project Congressional Districts if needed. Add Attachment Delete Attachment View Attachment 17. Proposed Project: * a. Start Date: 07/01/2016 ' b. End Date: 06/30/2017 18. Estimated Funding ($): • a. Federal 272, 699.00 • b. Applicant 0 . 00 *c. State 0.00 • d. Local 0.00 • e. Other 0.00 • f. Program Income 0.00 *g. TOTAL 272,699.00 • 19. Is Application Subject to Review By State Under Executive Order 12372 Process? Fla. 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. ® c. Program is not covered by E.O. 12372. ' 20. Is the Applicant Delinquent On Any Federal Debt? (If "Yes," provide explanation in attachment) F] Yes ®No If "Yes ", provide explanation and attach Add Attachment Delete Attachment View Attachment 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) ® ** I AGREE ** The list of certifications and assurances, or an intemet site where you may obtain this list, is contained in the announcement or agency specific instructions. Authorized Representative: Prefix: * First Name: Brian Middle Name: * Last Name: Dolan Suffix: *Title: Assistant City Manager * Telephone Number: 925- 931 -5002 Fax Number: *Email: bdolan @cityofpleasantonca.gov * Signature of Authorized Representative: * Date Signed: