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* a. Federal <br />* b. Applicant <br />* c. State <br />* d. Local <br />* e. Other <br />* f. Program Income <br />* g. TOTAL <br />. <br />Prefix:* First Name: <br />Middle Name: <br />* Last Name: <br />Suffix: <br />* Title: <br />* Telephone Number: <br />* Email: <br />Fax Number: <br />* Signature of Authorized Representative:* Date Signed: <br />18. Estimated Funding ($): <br />21. *By signing this application, I certify (1) to the statements contained in the list of certifications** and (2) that the statements <br />herein are true, complete and accurate to the best of my knowledge. I also provide the required assurances** and agree to <br />comply with any resulting terms if I accept an award. I am aware that any false, fictitious, or fraudulent statements or claims may <br />subject me to criminal, civil, or administrative penalties. (U.S. Code, Title 18, Section 1001) <br />** The list of certifications and assurances, or an internet site where you may obtain this list, is contained in the announcement or agency <br />specific instructions. <br />Authorized Representative: <br />Application for Federal Assistance SF-424 <br />* a. Applicant <br />Attach an additional list of Program/Project Congressional Districts if needed. <br /> * b. Program/Project <br />* a. Start Date:* b. End Date: <br />16. Congressional Districts Of: <br />17. Proposed Project: <br />04 04 <br />Add Attachment Delete Attachment View Attachment <br />07/01/2026 12/31/2026 <br />127,612.50 <br />37,537.50 <br />0.00 <br />0.00 <br />0.00 <br />0.00 <br />165,150.00 <br />a. This application was made available to the State under the Executive Order 12372 Process for review on <br />b. Program is subject to E.O. 12372 but has not been selected by the State for review. <br />c. Program is not covered by E.O. 12372. <br />Yes No <br />Add Attachment Delete Attachment View Attachment <br />** I AGREE <br />Travis <br />Myren <br />County Manager <br />919-245-2308 <br />tmyren@orangecountync.gov <br />* 20. Is the Applicant Delinquent On Any Federal Debt? (If "Yes," provide explanation in attachment.) <br />* 19. Is Application Subject to Review By State Under Executive Order 12372 Process? <br />If "Yes", provide explanation and attach <br />Docusign Envelope ID: B71E2DA6-1521-8CE2-806A-C1D1D7DFD770 <br />4/11/2026