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General Information

Contractor

Initiative

Contract Number

Commission Contract Monitor

Date Submitted

Contact Person

Phone Number

Email Address

Annual Contract Amount ($)

Projected Rollover Amount Requested ($)

Total Percentage(%)

Revised Budget Attachment (Limit 5MB)

If the revised budget is not attached, could you explain why?

Revised Budget Narrative Attachment (Limit 5MB)

If the revised budget narrative is not attached, could you explain why?

Revised Cost Allocation Plan Attach (Limit 5MB)

If the Revised cost Allocation Plan is not attached, could you explain why?

1. Identify each budget category (Personnel, Services/Supplies, Administrative Expenses) of unspent funding. Describe why the allocated funding was not expended.

2. Explain how the use of rollover funds will be tied to Direct Services

3. List the Outcomes or Direct Services that will be affected by the rollover funds. Also, explain how these outcomes will increase, or Direct Services will be enhanced by the rollover funds.

I hereby certify the information submitted herin is accurate and complete to the best of my knowledge.

Name

Title

Signature

Date

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