Request for Funds Template by Rabia06

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									                                                        Department of Health and Human Services
                                                                 Grants Management Unit
                                                      Financial Status Report and Request for Funds

Program Name                                                                 Prepared by:

Funding Source                                                               Address:

Grantee:                                                                     City, State, Zip

Tax ID #:                                                                    Phone:

Report Period: From:                                                         Fax:

                To:                                                          Email:

Report Number:                                                             Vendor #
                                                                           Allocate
                                                                                                    Current                                Total             Budget
                      Description                          Budget         Advance @                              Past Expenses
                                                                                                   Expenses                              Expended           Remaining
                                                                           Year End
Personnel and Benefits                                 $            -    $             -       $            -     $            -     $            -     $            -
Contractual/Consult                                    $            -    $             -       $            -     $            -     $            -     $            -
Staff Travel/Per diem                                  $            -    $             -       $            -     $            -     $            -     $            -
Equipment                                              $            -    $             -       $            -     $            -     $            -     $            -
Supplies                                               $            -    $             -       $            -     $            -     $            -     $            -
Occupancy                                              $            -    $             -       $            -     $            -     $            -     $            -
Communications                                         $            -    $             -       $            -     $            -     $            -     $            -
Public Information                                     $            -    $             -       $            -     $            -     $            -     $            -
Other Expenses                                         $            -    $             -       $            -     $            -     $            -     $            -
Advance (INITIAL ENTRY ON THIS LINE ONLY)              $            -    $             -                          $            -     $            -     $            -
Totals                                                 $            -    $             -       $            -     $            -     $            -     $            -


CURRENT AMOUNT REQUESTED

                                                                        CERTIFICATION

I, a duly authorized signatory for the applicant, certify that the data reported above is correct and all spending is in accordance with the approved grant
award and that the amount of the requested is not in excess either of current needs, or cumulatively for the grant term, in excess of the total approved
grant award. I request $                        in funds.




    Agency-Authorized Fiscal Signature                                         Title                                                      Date

DEPARTMENT OF HEALTH AND HUMAN SERVICES APPROVAL
Program Administration



         Authorized Program Signature                                          Title                                                      Date

Fiscal



            Authorized Fiscal Signature                                        Title                                                      Date

Submit to appropriate office for your grant administrator:
Carson City Office: 4126 Technology Way, Room 100 Carson City, NV 89706-2009 775 684-4000 (Tel) 775 684-4010 (Fax)
Las Vegas Office: 4220 S. Maryland Pkwy, Bldg B, Suite 302, Las Vegas, NV 89119 702 486-3530 (Tel) 702 486-3533 (Fax)




                                                                                           S:Grants Management Team Documents/FY06 Grantee Forms/request for funds template

								
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