Mosquito Control Grant Program

2017 Project Period Extension Request Form

Organization Name / Click or tap here to enter text.
Contact Person / Click or tap here to enter text.
Contact Phone / Click or tap here to enter text.
Contact Email / Click or tap here to enter text.
Date / Click or tap to enter a date.
Date Final Report Due / Click or tap to enter a date.
Award Amount / Click or tap here to enter text.

2017 Mosquito Control Grant Budget

In Table A, please input the amount of monies awarded for each Fundable Activity in the column: CURRENT BUDGET. The CURRENT BUDGET is the amount of monies awarded per Fundable Activity unless a Revised Budget has been approved; then input the approved Revised Budget as the Current Budget for each Fundable Activity.

As of the date this form was completed, input the sum of all expenses for each Fundable Activity in the column: EXPENDITURES TO DATE. Calculate and input the amount of unspent funds for each Fundable Activity in the column: REMAINING MONIES.

Table A: MCG Budget
FUNDABLE ACTIVITIES / CURRENT
BUDGET / EXPENDITURES TO DATE / REMAINING MONIES
1. Surveillance
2. Larval Control
3. Adult Control
4. Community Outreach
5. Source Reduction
6. Seasonal Employee(s)
7. Contracted Services
8. Monies Rounded
TOTALS

Note: Fundable Activity 8: Monies Rounded refers to the rounded dollar amount awarded above the original funding request.

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Answer each question in Table B by checking Yes (Y) or No (No)

Table B: Previous Approvals and Requests / Y / N
  1. Was a Project Period Extension previously requested and approved?
/ ☐ / ☐ /
  1. Was a Revised Budget Proposal submitted in conjunction with this request?
/ ☐ / ☐ /
  1. Was a Revised Budget Proposal submitted previously and separate from this request?
/ ☐ / ☐ /
  1. If Yes to Question 3, was the Revised Budget Proposal approved?(leave unchecked if not applicable)
/ ☐ / ☐ /

Project Period Extension Proposal

Please provide an explanation and justification for this request, including a project period end date and a proposed timeline for completing the scope-of-work in Exhibit A of the grant contract:

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Authorized Official Signature

Upon submission of this project period extension request, the applicant will be bound by its contents. In the event Ohio EPA approves this project period extension request, the applicant will fully comply with the contents and conditions outlined in the project period extension approval.

I, the undersigned Authorized Official of the grant application, certify that the applicant possesses all necessary authority to undertake the proposed activities identified in this project period extension request. I certify the information in this project period extension request is accurate and complete.

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(Authorized Official’s Printed Name) / (Authorized Official’s Title)
(Authorized Official’s Signature) / (Date)

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For Ohio EPA Use Only

Date Project Period Extension Request Received:

Current Final Report Due Date:

Project Period Extension Request Approval/Denial / Y / N
Was this request submitted within 90 days of the end of the project period? / ☐ / ☐ /
Does the Project Period Extension Request contain all required information? / ☐ / ☐ /
Project Period Extension Request Approved? / ☐ / ☐ /
Enter Revised Project Period and Final Report Due Date:
Enter Date of Approval/Denial:
Approved/Denied By:
Reason for Denial, if Applicable

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