Designation of Grant Officials Change Form

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As a condition of receiving grant funds from Texas CASA, you are required to provide and keep current the name and contact information for the executive director, president and treasurer of your organization. If there is a change in the name or contact information of any of these individuals you are required to notify Texas CASA within 10 business days of the change using this form. You are also required to provide a sample signature of any new official as provided on this form.

A. SELECT All that apply for these change(s):  Official or  Address/Phone/Fax/Email

B. ENTER Local CASA’s information

1. Provide the Grant Number(s) affected by these changes (VOCA, CVC, Swalm, WFACF, 421):
2. Legal Name of the Organization:
/ 3. Effective Date of Change:

C. ENTER the change(s) for the Executive Director:  Mr.  Ms.  Dr.  Judge  Other ______

Executive Director Name
/ Signature of Executive Director
Official Mailing Address / E-Mail Address
Daytime Telephone & Extension / Fax Number

D. ENTER the change(s) for the Board President:  Mr.  Ms.  Dr.  Judge  Other ______

Board President Name / Signature of Board President
Official Mailing Address / E-Mail Address
Daytime Telephone & Extension / Fax Number

E. ENTER the change(s) for the Board Treasurer:  Mr.  Ms.  Dr.  Judge  Other ______

Board Treasurer Name
/ Signature of Board Treasurer
Official Mailing Address / E-Mail Address
Daytime Telephone & Extension / Fax Number

F. Additional Designee for Financial Reports: As an additional condition of the grant the treasurer is required to sign any request for grant funds submitted to Texas CASA. Our rules, however, allow the treasurer to delegate this responsibility to either a fellow board member or a staff member with direct responsibility for the preparation of reimbursement requests. The treasurer cannot delegate this responsibility to the Board President or the Executive Director. This does not relieve the treasurer of responsibility for the accuracy of requests and treasurer should ensure procedures are in place and followed to ensure accuracy. Unless requested otherwise by the treasurer, financial information prepared by Texas CASA in connection with requests for grant funds will be sent to the delegated individual.

Designee Name (Please Print) / E-Mail Address / Position & Telephone Number
Signature of Designee / Signature of Board Treasurer

Revised – July 19, 2016