Contnuaton Leter Of Intent Form Youth Services
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1Department of Youth Services Diversion Program
"Continuation Letter of Intent Form" for FY 2016-2017
Email form to: becky.hathcock@dys.alabama.gov Deadline: May 16, 2016
1
County Name (Payee)
2
Program Name
3
Counties Served by Program
4
Amount Requested for FY16-17
Estimated Unexpended Grant Funds
* 5
as of Sept. 30, 2016
Net Requested Funds
6
(line 4 - line 5)
7
FY16 (current yr) Grant Amount
Proposed Program Changes
8
(if applicable)
Affect of Proposed Changes
9
(Reduced Commitments /
Financial Savings, etc.)
10
Submitted by (print or type)
title
contact information
date
signature
All DYS funded diversion programs will be required to submit a competitive grant application during the Spring of 2017
for the 2017-2018 fiscal year. This includes new diversion programs and all programs receiving Medicaid funds
processed through the Department of Youth Services.
*
Actual unexpended funds must be reported to DYS at close of current fiscal year.
"For DYS Use Only"
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