Free 52732.xls - Indiana

REQUEST FOR MODIFICATION CONTRACT TERMINATION
State Form 52732 (7-06) INDIANA WORKFORCE DEVELOPMENT

Grantee Information Contract Number: Applicant Name: Address: City, State, Zip:

Grantees should complete this form to terminate their training grant for non-completion of the project prior to the contractual end date. Unused training funds will be de-obligated and the agency will not be liable for services performed after the effective date of the termination.

Balance left in grant: Reason for Termination

Effective date of termination:

Send to: Attn: Market Development Indiana Department of Workforce Development 10 North Senate Avenue SE205 Indianapolis, Indiana 46204

For any inquiries: www.in.gov/dwd Telephone: 1-800-465-4616 Fax: 317-232-1821

Applicant Authorization:

Name and Title

Date