State of Utah

STATE OF UTAH
Commission on Criminal & Juvenile Justice
Utah State Capitol Complex, Suite E330
PO Box 142330
Salt Lake City, Utah 84114-2330
(801) 538-1031 Fax: (801) 538-1024 / 1. Grant #
Name:
2. Grant Program
3. Grantee: / 4. Nature of Adjustment
Address: / Extension to:
Phone # / Fax # / Budget Adjustment
5. Grant Change Request Number: / Other:
6. Budget Summary (to be completed only if requesting a Budget Adjustment)
Item / Total Costs / Grant Funds / Cash Match / In-kind Match
Request / Current / Request / Current / Request / Current / Request / Current
Personnel
Contracts
Equipment/
Supplies/Operating
Travel
TOTAL COSTS:
7. Justification for the adjustments being made in request (Use as much space as necessary - form will expand)
Grant Program Director (Signature) / Date: / Approved by CCJJ Official (Signature) / Date: