Free 52731.xls - Indiana

MODIFICATION REQUEST FOR TRAINING ACCELERATION GRANT (TAG)
State Form 52731 (7-06) INDIANA WORKFORCE DEVELOPMENT

Grantee Information Grant Number: Grantee Name: Address: City, State, Zip: Phone Number: Modification Current Contractual Agreement Budget Impact
Please complete this section when any requested modification will change the amount allocated to any category i.e. monies are being moved from "books"(indicate as a negative number) and added to "Contracted Services"(indicate as a positive number). When amounts are entered for the Requested Modification the Modified Budget Total will be calculated.
Current Budget 1. Books 2. Lab Fees 3. Tuition 4. Contract Services sub-total 5. Administration 0% TOTAL Requested Modifications (+/-) Modified Budget Total

Date:

Proposed Modification

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Outcomes (credentials/degrees) Type: Name: Number: Curriculum Description: Description: Type: Name: Number:

Number: Training Provider Name: Address Name: Address

Number:

Contact Name:

Contact Name: Time Extension

End Date:

End Date: Number of Trainees

Number of Trainees: Name Change Grantee Name: Employer Name (if consortium):

Number of Trainees:

Grantee Name: Employer Name (if consortium):

Modification - continued Removal/Addition of Employer (if consortium) Employer Name: Street Address: City, State, Zip: Phone: FEIN: Type of Training: Number of Employees: Number of Trainees: Number of Credentials: Employer Name: Street Address: City, State, Zip: Phone: FEIN: Type of Training: Number of Employees: Number of Trainees: Number of Credentials:

Removal/Addition of Grant Administrator Name: Street Address: City, State, Zip: Phone: Email: Please explain why you would like to make this/these modifications. Name: Street Address: City, State, Zip: Phone: Email:

Will your modification adjust any line item in the budget? (check one) attach a copy of the original budget.

Yes

No

If yes, please explain how the budget will change, and

Send To: ATTN: Market Development Indiana Department of Workforce Development 10 N. Senate Avenue, SE205 Indianapolis, IN 46204-2277

For Any Inquires Contact: www.in.gov/dwd Phone: 1-800-465-4616 Fax: 317-232-1821 Application Authorization

Signature

Date Internal Use Only Approved by: Date:

Printed Name and Title ____________________________ _______________