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OMB Approval No. 29 -RO218 <br />STANDARD FORM 424 PARE 1 (10 -75) <br />Prescribed by GSA, Federal Management Circular 74-7 <br />FEDERAL ASSISTANCE <br />2. APPLI- <br />a. NUMBER <br />3. STATE <br />a. NUMBER <br />APPLJCA- <br />7804180271 <br />CANTS <br />APPLI- <br />- <br />TION <br />IDENTI• <br />- <br />1. TYPE REAPPLICATION <br />❑ <br />b. DATE <br />- - <br />b. DATE Year month day <br />OF <br />ACTION APPLICATION <br />CATION <br />1' car month day <br />19 �Q 1 <br />FIER <br />ASSIGNED 19 78 7 <br />(Mark ap. ❑ NOTIFICATION OF INTENT (OPL) <br />Leave <br />propriate <br />box) ❑ REPORT OF FEDERAL ACTION <br />Blank <br />4. LEGAL APPLICANT /RECIPIENT <br />5. FEDERAL EMPLOYER IDENTIFICATION NO. <br />a. Applicant Name : City of South Bend Youth Service Bure <br />1-35-600-1201-Al <br />b. Organization Unit <br />c. Street /P.O. Box 121 South Michigan Street <br />PRO- <br />a. NUMBER 11131 as 6 12 13 1 <br />b. TITLE <br />d. city South Bend, .. County : St. Joseph <br />GRAM <br />I. stag Indiana 46601 <br />g. ZIP Code: <br />(From <br />Federal <br />h. Contact Person (Name Bonnie C. Strycker <br />catalag) <br />Runaway Youth Projects <br />& telephone No.) - <br />7. TITLE AND DESCRIPTION OF APPLICANTS PROJECT <br />8. TYPE OF APPLICANT /RECIPIENT <br />Runaway Youth Project - Youth Service Bureau Runa- <br />A-State H- Community Action Agency <br />B- Inters tate <br />96 <br />w Shelter is a temporar shelter facility for <br />way Y Y <br />1- Higher Educational Institution <br />G-subeat. J- Indian Spe <br />Di :erlee K -Ocher (Specify) <br />youth with provision for short and long term indi- <br />ECity' <br />vidual and fan-Lily counseling, e � to Y ent etc., <br />F- School District <br />secl.i <br />G- Parpase <br />D trict Enter letter <br />through direct service or referral. <br />appropriate { <br />9. TYPE OF ASSISTANCE <br />A -Basic Grant D- Insurance <br />p <br />B-Supplemental Grant E -Other Enter appro- <br />153 <br />C-Loan priate letter(&) <br />i3r <br />10. AREA OF PROJECT IMPACT (Names of cities, counties. <br />11. ESTIMATED NUM- <br />12. TYPE OF APPLICATION <br />States, etc.) <br />BER OF PERSONS <br />A-New C- Revision E- Augmentation <br />BENEFITING <br />B- Renewal D- Continuation <br />Primarily St. Joseph County <br />500 <br />Enter appropriate letter <br />13. PROPOSED FUNDING 14. CONGRESSIONAL DISTRICTS OF: <br />15. TYPE OF CHANGE (For Igo or zte) <br />A- increase Dollars F -Other (specify): <br />B- Decrease Dollars <br />a. FEDERAL <br />S 2 00. .00 <br />a. APPLICANT <br />b. PROJECT <br />C-Incresse Duration <br />b. APPLICANT <br />.00 <br />3 <br />3 <br />D- Decrease Duration <br />E- Cancellation <br />c. STATE <br />17,988. 00 <br />16. PROJECT START <br />17. PROJECT <br />DATE Y qr mom y <br />�U d <br />DURATION <br />Enter appro- <br />�1 <br />p <br />d. LOCAL <br />7,098. . .00 <br />19 <br />12 Months <br />priate letter(e) <br />e. OTHER <br />(]20. .00 <br />18. ESTIMATED DATE TO Year month day <br />19. EXISTING FEDERAL IDENTIFICATION NUMBER <br />BE SUBMITTED TO <br />FEDERAL AGENCY ► 19 80 4 1 <br />YD- IN -Q ^- 6- <br />I. TOTAL <br />1402,076. .00 <br />20. FEDERAL AGENCY TO RECEIVE REQUEST (Name, City, State, Z/P code) <br />21. REMARKS ADDED <br />OS Region on V Chic Illinois 60606 <br />E2 Yes 0 No <br />22. <br />a. To the best of my knowledge and belief, <br />b. If required by OMB Circular A-95 this application was submitted, pursuant to in- No re- Response <br />4 <br />data in this preapplication /application are <br />structions therein, to appropriate clearinghouses and all responses are attached: spouse attached <br />THE <br />true and correct, the document has been <br />APPLICANT <br />duly authorized by the governing body of <br />❑ 1:1 <br />CERTIFIES <br />the applicant and the applicant will comply <br />(1) <br />THAT ► <br />with the attached assurances if the assist- <br />(2) ❑ ❑ <br />11 <br />ancT(Y2approved. <br />(3) ❑ ❑ <br />23. <br />a. TYPED NAME AND TITLE <br />b. SIGNATURE <br />c. DATE SIGNED <br />G <br />INCA <br />Bonnie C. Strycker <br />r month day <br />RE RE- <br />SENTATIVE <br />Executive Director <br />G �^ ->�� <br />_- 17 <br />24. AGENCY NAME <br />PPLIC/1 Year month day <br />TION <br />RECEIVED 19 <br />26. ORGANIZATIONAL UNIT <br />27. ADMINISTRATIVE OFFICE <br />28 FEDERAL APPLICATION <br />it <br />IDENTIFICATION <br />0 <br />29. ADDRESS <br />30. GRAN <br />DENT FI <br />31. ACTION TAKEN <br />32. FUNDING <br />Year month day <br />34. Year month day <br />STARTING <br />❑ a. AWARDED <br />a. FEDERAL <br />j .00 <br />33. ACTION DATE ► 19 <br />DATE 19 <br />b. REJECTED <br />b. APPLICANT <br />,00 <br />35. CONTACT FOR ADDITIONAL INFORMA• <br />36. Year ruonth day <br />TION (Name and telephone number) <br />ENDING <br />E] c. RETURNED FOR <br />c. STATE <br />.00 <br />DATE 19 <br />d. LOCAL <br />.00 <br />37. REMARKS ADDED <br />AMENDMENT <br />C <br />d. DEFERRED <br />e. OTHER <br />.00 <br />I. TOTAL <br />i .00 <br />e. WITHDRAWN <br />Yes ONo <br />38. <br />a. In taking above action, any comments received from clearinghouses were con. <br />b. FEDERAL AGENCY A-95 OFFICIAL <br />sidered. If agency response is due under provisions of Part 1, OMB Circular A-95, <br />(Name and telephone no.) <br />FEDERAL AGENCY <br />it has been or is being made. <br />A-95 ACTION <br />STANDARD FORM 424 PARE 1 (10 -75) <br />Prescribed by GSA, Federal Management Circular 74-7 <br />