Dhses-55 - Budget Amendment/grant Extension Form (Page 2 of 2) in pdf

INSTRUCTIONS FOR FILING THE BUDGET AMENDMENT/GRANT EXTENSION REQUEST FORM

This form replaces all other Budget Amendment/Grant Extension Requests for both State and Federal

funds. All grantees are required to submit this form for any adjustments to their budget and/or to obtain an

extension to their grant period, if appropriate.

SUBMIT SIX (6) COPIES OF THIS FORM.

ITEMS 1-5:

Obtain information from the contract and associated material, correspondence, etc.

ITEM 6: Check the appropriate box (es) for this request (Budget Reallocation, Budget Increase/Decrease,

Grant Extension, Start Date).

ITEM 7: Obtain information from application for grant.

ITEM 8: Enter the preparation date of this request.

ITEM 9: Enter date of the last approved request, i.e., the last Budget Amendment/Grant Extension

Request submitted to DHSES and returned approved to you; if none, enter "none".

ITEM 10:

Enter the effective beginning date of the contract to the termination date of the contract or

contract extension, if an extension was requested and approved by DHSES.

ITEM 11:

If you are requesting an extension of the contract, enter the date that will be the new

requested termination date of the contract. A contract extension is not possible under

some circumstance. Check with your Representative at DHSES.

ITEM 11a:

If you are requesting a new start date of the contract, enter the date that will be the new

requested start date of the contract. A new contract start date is not possible under some

circumstances. Check with your Representative at DHSES.

ITEM 12:

Requested Budget Amendment information must be entered in columns A - C, and in

rows A - I.

Approved Project Budget:

Enter the present operating budget. It must be in effect as of the date entered in ITEM 9.

Proposed Transfers:

These columns should reflect dollar amounts and categories to be affected by the

proposed fund transfer or increase. (Example: Category D, Equipment, + $2,500,

Category E, Supplies, -$2,500). Changes in the grantee share as well as requested

transfer of DHSES funds should be reflected.

Requested Operating Budget:

This should reflect the newly proposed budget. If the request is approved, these two

columns will become the new current operating budget for the project. Only upon receipt

of written approval from DHSES of the Budget Revision/Grant Extension Request will the

requested operating budget become the operating budget. Grantees should never make

adjustments to their Grant Awards until written approval is received. New budget

amounts, once approval is received, should be reflected on all subsequent Monthly Fiscal

Cost Reports to DHSES. Do not report proposed changes on Monthly Fiscal Cost

Reports prior to the receipt of written approval by DHSES.

ITEM 13:

AMENDMENT JUSTIFICATION (ATTACH ADDITIONAL PAGES AS NECESSARY).

Grantee Signature – Necessary to request contract changes.

ITEM 14:

ADDENDA:

SUPPORT MATERIAL (ATTACH PAGES AS NECESSARY).

FOR DHSES USE ONLY:

Completed by DHSES

SIX (6) SIGNED AND NOTARIZED ORIGINALS OF APPENDIX X MUST BE ATTACHED

TO THIS FORM FOR BUDGET INCREASES, DECREASES, GRANT EXTENSIONS

OR START DATE CHANGES.

BUDGET REALLOCATIONS REQUIRE THIS FORM AND A SIGNED LETTER FROM THE GRANTEE.

Should any questions concerning this form arise, contact your Representative at DHSES

Dhses-55 - Budget Amendment/grant Extension Form Page 2

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