Designation Of Grant Officials Change Form
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1Designation of Grant Officials Change Form
Texas CASA, Inc. - Grants Management
1501 West Anderson Lane, Suite B-2, Austin, Texas 78757
(512) 473-2627 (phone) (512) 610-6134 (fax)
As a condition of receiving grant funds from Texas CASA, you are required to provide and keep current the name
and contact information for the executive director, president and treasurer of your organization. If there is a
change in the name or contact information of any of these individuals you are required to notify Texas CASA
within 30 days of the change using this form. You are also required to provide a sample signature of any new
official as provided on this form.
Official
or
Address/Phone/Fax/Email
A. SELECT All that apply for these change(s):
B. ENTER Local CASA’s information
1. Provide the Grant Number(s) affected by these changes (VOCA, CVC, Swalm, WFACF, 421):
2. Legal Name of the Organization:
3. Effective Date of Change:
C. ENTER the change(s) for the Executive Director: Mr. Ms. Dr. Judge
Other ___________
Executive Director Name
Signature of Executive Director
Official Mailing Address
E-Mail Address
Daytime Telephone & Extension
Fax Number
D. ENTER the change(s) for the Board President: Mr. Ms. Dr. Judge
Other ___________
Board President Name
Signature of Board President
Official Mailing Address
E-Mail Address
Daytime Telephone & Extension
Fax Number
E. ENTER the change(s) for the Board Treasurer: Mr. Ms. Dr. Judge
Other ___________
Board Treasurer Name
Signature of Board Treasurer
Official Mailing Address
E-Mail Address
Daytime Telephone & Extension
Fax Number
F. Additional Designee for Financial Reports: As an additional condition of the grant the treasurer is required
to sign any request for grant funds submitted to Texas CASA. Our rules, however, allow the treasurer to delegate
this responsibility to either a fellow board member or a staff member with direct responsibility for the preparation
of reimbursement requests. The treasurer cannot delegate this responsibility to the Board President or the
Executive Director. This does not relieve the treasurer of responsibility for the accuracy of requests and treasurer
should ensure procedures are in place and followed to ensure accuracy. Unless requested otherwise by the
treasurer, financial information prepared by Texas CASA in connection with requests for grant funds will be sent
to the delegated individual.
Designee Name (Please Print)
E-Mail Address
Position & Telephone Number
Signature of Designee
Signature of Board Treasurer
Revised February 5, 2013
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