Rev. 11/05

Page I.

Ryan White Part A

Budget Modification - Justification

Line item budget modification must be attached when shift in services occur or change in total dollar

Agency: ______Date: ______

Address: ______Contract #: ______

______Contract Year: ______

I. Transfer of Service Categories:

List ALL service categories regardless of change.
SERVICE CATEGORY / CURRENT ALLOCATION / Adjustments
+ or (-) / REVISED FUNDS

II. Rationale for Proposed Changes:

Note any adjustments to personnel cost

Position/Name / Annual Salary / Rate/Hour/Wk. / Duration / Total Adj. + or (-) / Fringe
Budget Line Item / Justification

___ Yes, Program modification attached ___Check here if additional pages are attached

______

Signature and Title of Authorized Representative

For Office Use:

Date Received: Fiscal Officer Program Analyst Program Director

______

Resubmission Date(s):

______

______

Ryan White Part A

Program Modification

Agency: ______Date: ______

Address: ______Contract #: ______

______Contract Year: ______

Program Description:

List ALL service categories regardless of change.

SERVICE CATEGORY / CONTRACTUAL / ADJUSTMENT
+ or (-) / REVISION / UNIT COST
Clients / Units / Clients / Units / Clients / Units

Rationale for Proposed Changes:

Describe the program and client impact and rational for proposed change.

ٱ Yes, Budget Modification is attached. Check here ٱ if additional pages are attached.

______

Signature and Title of Authorized Representative

For Office Use:

Date Received: Fiscal Officer Program Analyst Program Director

______

Resubmission Date(s):

______

______