Grant Modification Request

GRANT MODIFICATION REQUEST

$7,500

Grant Number:

Applicant Organization:

Project Name:

Project Director/Sole Contact:(include name, address, phone number and email address)

Name:

Address:

City: State: Zip:

Phone Number:

Email Address:

Amount of approved match:

Beginning Project date:

Ending Project date:

Modifications to date, including this one (select one):

1 2 3 4 5 6 (no more than six modifications per grant):

Please provide all the following information:

Does this modification include an extension? Yes. No.

If yes, list requested new ending project date?

If yes, is the extension for over six months after the original ending project date? Yes No

Has this grant received a prior extension? Yes. No. If so, list new ending project date:

Does this modification include movement of or revision to media? Yes. No.

Does this modification include a request for additional funding, over the original match amount?

Yes. No.

If yes, please indicate the state’s share of the increase $

Number of items to be modified within the grant as a result of this request:

Include a complete narrative description of each proposed item change (mandatory – also see media breakout requirement below) If this is an extension request, you must provide a complete explanation, and submit at least 30 days prior to the current ending project date:

IMPORTANT NOTICE:

·  If this modification request is the first in your grant and includes movement of media you must attach a complete original media breakout plus a complete revised media breakout with proposed changes.

·  If the grant has been previously modified, you must include the latest complete approved version of the media breakout along with a complete revised media breakout with proposed changes.

·  Modifications must have prior written approval.

·  Please be advised that use of the West Virginia Wild and Wonderful brand identity is restricted within the grant period and does not apply to extensions except where specifically authorized by item. Logo use that is not authorized is required to be covered or removed from all applicable advertising.

·  Modifications requiring Commission approval must be submitted at least 30 days prior to the Commission meeting.

·  Increases in funding may not exceed the minimum match requirement for large grants ($10,000), or the maximum allowable match in the small grants ($7,500) or Fair and Festival grants ($5,000).

·  No modifications shall be granted after the end of the grant period.

·  If you need an extension, it MUST be at the Division 30 days before the ending project date.

·  If your modification is moving media it MUST be in before the ending project date listed on the grant.

·  Grant awards MUST be closed out within 90 days of the Ending Project Date listed on the grant.

Applicant: ______

Signature Date

Approved Division of Tourism: ______

Signature Date

Approved Tourism Commissioner: ______

Signature Date

1

Grant Modification rev.2/23/07 – 25

WV Division of Tourism • 90 MacCorkle Ave. SW • South Charleston, WV 25303 • 304-558-2200 • Fax 304-558-4893