Program Amendment Request

Program Amendment Request
Subgrantee
School Year
Project Director's Name

First NameLast Name
Project Director's Email
example@example.com
Project Director's Phone Number
Format: (000) 000-0000.
Type of Amendment
Program Amendment Request
What is the justification for the Program Change?
Explain how the change is reasonable and necessary for the successful program implementation.
What is the service/support requested to be added or removed?
How will the change affect the program in meeting the program objectives, goals, and/or key performance indicators?
How does the change maintain the integrity of the original program proposal?
How will this change impact student attendance, participation, or enjoyment?
Budget Change Request
How does the change maintain the integrity of the original proposal?
Please specifically refer to the budget in the original proposal.
What is the justification for the change?
Why are you requesting the change? What circumstances impact the request?
Explain how the request is reasonable, necessary, allowable, and documentable.
Confirm that the new amounts are equal to or less than the total annual award.
Original Budget

Please upload a copy of your original budget.
Cancelof
Template forms if needed.

Budget Modification Form
Budget Modification

Attach the budget modification using the original budget worksheet with original values and new requested values by line item.
Cancelof
Budget Narrative

Attach revised budget narrative using the original budget narrative with original text struck out and new text added as bold. Note: The budget narrative and worksheet figures must match. Failure to provide sufficient detail will result in a denied change request.
Cancelof
Additional Documents

If it would help for clarity, submit the pertinent section of the approved application with strike outs in text for services/supports to be removed and bold text for services/supports to be added.
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This form must be signed and submitted by the project director. For questions, contact the 21CCLC Team at (808) 305-0698 or 21cclc@k12.hi.us.
Signature
Project Director Signature
Should be Empty:

Program Amendment Request

Program Amendment Request

Budget Change Request