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OMB Number: 4040-0004 C-22-17-060-G-11 Expiration Date: 10/31/2019 Application for Federal Assistance SF-424 * 1. Type of Submission: * 2. Type of Application: * If Revision, select appropriate letter(s): Preapplication New Other Application Continuation * Other (Specify): Changed/Corrected Application Revision Budget Revision * 3. Date Received: 4. Applicant Identifier: 09HP000105 5a. Federal Entity Identifier: 5b. Federal Award Identifier: N/A 09HP000105 State Use Only: 6. Date Received by State: 7. State Application Identifier: 8. APPLICANT INFORMATION: * a. Legal Name: MARICOPA, COUNTY OF * b. Employer/Taxpayer Identification Number (EIN/TIN): * c. Organizational DUNS: 866000472 050391270 d. Address: * Street1: 234 N Central Ave Street2: Fl 3 * City: Phoenix County/Parish: Maricopa County * State: AZ: Arizona Province: * Country: USA: UNITED STATES * Zip / Postal Code: 85004-0948 e. Organizational Unit: Department Name: Division Name: Human Services Early Education Division f. Name and contact information of person to be contacted on matters involving this application: Prefix: Ms. * First Name: Eve Middle Name: * Last Name: Del Real Suffix: Title: Assistant Director Organizational Affiliation: MCHSD Early Education Division * Telephone Number: (602) 372-3710 Fax Number: * Email: eve.delreal@maricopa.gov C-22-17-060-G-11 Application for Federal Assistance SF-424 * 9. Type of Applicant 1: Select Applicant Type: County Government Type of Applicant 2: Select Applicant Type: Type of Applicant 3: Select Applicant Type: * Other (specify): * 10. Name of Federal Agency: ACF-Head Start 11. Catalog of Federal Domestic Assistance Number: 93.600 CFDA Title: Head Start * 12. Funding Opportunity Number: eGrants-N/A * Title: N/A 13. Competition Identification Number: Not Applicable Title: Not Applicable 14. Areas Affected by Project (Cities, Counties, States, etc.): Maricopa County, Excluding the City of Phoe * 15. Descriptive Title of Applicant's Project: EARLY HEAD START EXP NFS WAIVER REQUEST Attach supporting documents as specified in agency instructions. C-22-17-060-G-11 Application for Federal Assistance SF-424 16. Congressional Districts Of: * a. Applicant AZ-007 b. Program/Project AZ-003,AZ-004,AZ-005,AZ-006 Attach an additional list of Program/Project Congressional Districts if needed. 17. Proposed Project: * a. Start Date: 09/01/2020 * b. End Date: 08/31/2021 18. Estimated Funding ($): * a. Federal 0 * b. Applicant -298,894 * c. State * d. Local * e. Other 0 * f. Program Income * g. TOTAL -298,894 * 19. Is Application Subject to Review By State Under Executive Order 12372 Process? a. 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.) Yes No If "Yes", provide explanation and attach 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 internet site where you may obtain this list, is contained in the announcement or agency specific instructions. Authorized Representative: Prefix: Mr. * First Name: Jack Middle Name: * Last Name: Sellers Suffix: * Title: Chairman, Maricopa County Board of Supervisor * Telephone Number: (602) 506-1776 Fax Number: * Email: sellersj@mail.maricopa.gov * Signature of Authorized Representative: * Date Signed: