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(Pad..age H,,,'iwd 12/23/03)
APPLICATION FOR 2. DATE SUBMITTED Appicant Identifier
FEDERAL ASSISTANCE
1. TYPE OF SUBMISSION: . 3. DATE RECEIVED BY STATE State App/ication IdeOOfier
Application
~ Construction ~1Cation 4. DATE RECEIVED BY FEDERAL AGENCY F ederalldenlifier
o Non-Construction o ConStruction AlP 3-41..()002..()6
o Non-Construction
5. APPUCANT INFORMATION
Legal Name: Organizational Unit:
Ashland Municipal Airport Department City of Ashland
Organizational DUNS: Division:
Address: Name and telephone number of person to be contacted on
Street: 20 E Main Street matters Involving this application (give area code)
Prefix: Ms. I FIrSt Name: Pa:ula
City: Ashland Middle Name:
County: Jackson Last Name: Brown
State: OR 1 Zip Code: 97520 Suffix:
.
Country: USA Email:
6. EMPLOYER IDENTIFICA nON NUMBER (Elf./): Phone number (give Phone
area code): number (give
area code):
19131-161010121111171 541-488-5347
8. TYPE OF APPLICATION: 7. TYPE OF APPUCANT: (See back Clf form for ApplIcation Types)
r81New o Continuation o Revision rn
Other (specify)
If Revision, enter appropriate letter(s) In box(es): 0 0
(See back of fonn for c:Iescription of Iettets)
'.
Other (specify)
9. NAME OF FEDERAL AGENCY
--~-_._-_._-~------ -Eederal-Aviation-Administration~-----{-----~_."
10. CATALOG OF FEDERAL DOMESnc ASSISTANCE NUMBER 11. DESCRIPTIVE TITLE OF APPUCANT'S PROJECT:
~-~ 2004 Airport Improvements
TITlE:
12. AREAS AFFECTED BY PROJECT (cities. counties. states, etc.):
City of Ashland, Jackson County, State of Oregon
13. PROPOSED PROJECT 1... CONGRESSIONAL DISTRICTS OF
Start Date I Encing Date a. Applicant II b. Project
7/04 10/04 aecond Second
15. ESTIMATED FUNDING ~6. IS APPUCA TION SUBJECT TO REVIEW BY STATE EXECUTIVE
ORDER 12372 PROCESS
a. Federal. $ 875,632 .vii a. Yes. 0 THIS PREAPPlICA11ONIAPflllCATlON WAS MA.DE
AVAIlABLE TO THE STATE EXECUTIVE ORDER 12372
b. Applicant $ 46,086 .vii PROCESS FOR REVIEW ON
"
. c. State $ .w DATE:
d. local $ .w l>. No. D PROGRAM IS NOT COVEREID BY E. O. 12372
e. Other $ .w 0 OR PROGRAM HAS NOT BEIE~ SELECTED BY STATE FOR
, REVIEW
f. Program income $ .w 17. IS TIlE APPLICANT DEUNQUENT ON N:N fEDERAL DEBT?
g. TOTAl $ -921,718 .w Dves If .Yes. attach an explanation t81 No
18. TO THE BEST OF MY KNOWLEDGE AND BEUEF, ALL DATA IN THIS APPUCATIONlPREAPPLlCATION ARE '~UE AND CORRECT, THE
DOCUMENT HAS BEEN DULY AUTHORIZED BY .THE GOVERNING BODY OF THE APPUCANT AND THE APPUCAINT YVJLL COMPLY WITH THE
ATTACHED ASSURANCES IF THE ASSISTANCE IS AWARDED
a. Authorized R tive '-
Prefix Ms. I First Name Paula Middle Name
Last Name Brown Suffix
b. Title Public Works Director c. Telephone number (give area code)
541-488-5347
d. Signature of Authorized Representative ~ L /.d_ e. Date Signed
- ~ 1% JNI,. ()+
/F .vvr · r
Previous Editions Not Usable ; Standard Form 424 (Rev. 9-2003J
Authorized for Local Reproduction
Version 7/03
Prescribed by OMB Circular A-1 02