Dhses-55 - Budget Amendment/grant Extension Form

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DHSES-55 (03/09)
Please return to:
BUDGET AMENDMENT/GRANT EXTENSION
NYS Division of Homeland Security and Emergency Services
State Office Building Campus – Bldg. 7A
1220 Washington Avenue Suite 610
Albany, NY 12242
FEDERAL FUNDS
STATE FUNDS
X
1. GRANTEE:
2. COUNTY:
3. CONTRACT NUMBER:
____________
4. IMPLEMENTING AGENCY:
5.
DHSES NUMBER: _______________________________
6. TYPE OF REQUEST:
BUDGET REALLOCATION
BUDGET INCREASE
BUDGET DECREASE
GRANT EXTENSION
START DATE
___ WORKPLAN CHANGE
7. PROJECT TITLE:
8.
DATE OF REQUEST:
9. DATE OF LAST APPROVED REQUEST:
10. CONTRACT DURATION:
/
/
TO
/
/
11. REQUESTED TERMINATION DATE:
/
/
11a. REQUESTED NEW START DATE:
/
/
12.
REQUESTED BUDGET AMENDMENT
A. APPROVED PROJECT BUDGET
*B. PROPOSED TRANSFER
C. REQUESTED OPERATING BUDGET
CASH/
CASH/
CASH/
CATEGORY
STATE/FEDERAL
OTHER MATCH
STATE/FEDERAL
OTHER MATCH
STATE/FEDERAL
OTHER MATCH
A. PERSONNEL
B. FRINGE BENEFITS
C. CONSULTANTS
D. EQUIPMENT
E. SUPPLIES
F. TRAVEL
G. RENT
H. ALT & RENOVATIONS
I. ALL OTHER
TOTAL
13.
AMENDMENT JUSTIFICATION (attach additional sheets if necessary): ________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________
14. This document is submitted as a request to modify current contract: ____________________________________________________
Grantee Signature
DHSES USE ONLY
APPROVED
DENIED
APPROVED WITH CONDITIONS (SEE ATTACHED)
APPROVED
DENIED
APPROVED WITH CONDITIONS (SEE ATTACHED)
Program Sign
________________________________________________________
Fiscal Sign
________________________________________________________
Title
________________________________________________________
Title
________________________________________________________

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