Fillable Attachment One - Certification and Authorization- Contract Amendment (Arizona)

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Attachment One - Certification and Authorization- Contract Amendment (Arizona)

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Attachment One - Certification and Authorization- Contract Amendment
Grantee’s Chief Executive Officer authorizes this VDF Contract Amendment Request? Yes □ No □
An officer of Grantee’s governing body (such as a board member) must sign this VDF Grant Contract Amendment Request.
The undersigned, an authorized officer of the Grantee organization, does hereby certify that the information set
forth in this VDF grant proposal is true and correct; that the federal tax exemption determination is valid and the
present operation of the grantee organization and its current sources of support are not inconsistent with the
Grantee organization’s continuing tax exempt classification. Furthermore, monies provided under this VDF grant
will be used only for the proposed purpose. Misuse of monies or failure to provide the required reporting
documentation is, including but not limited to, cause for denial of any future grant request or proposal to ADVS.
Name (Print)
Title or Position
Organization Name
Signature
Date
Acceptance of Proposal and VDF Grant Contract Amendment Request
(For ADVS Use Only)
1. By this notice, you, the grantee, are notified of the Department’s decision to either approve or decline, your written VDF
Grant Contract Amendment Request to revise your Scope of Work and/or expenditures for initial VDF Grant received,
accepted, reviewed and considered by the Department.
The Department accepts and approves your VDF Grant Contract Amendment: ☐
OR
The Department does not accept your VDF Grant Contract Amendment. If you are unable to carry out your objectives under
your current Scope of Work any remaining VDF Grant monies must be returned to the Department: ☐
2. If your proposal is accepted as described above, you are now bound to perform as Grantee based upon the VDF Grant
as granted above.
You are hereby cautioned not to commence any work or provide any material or service under this VDF Grant until you
receive a VDF Grant release document, or written notice to proceed, if applicable, from the VDF Program Manager.
Awarded this _______ day of _______________, 2021.
_____________________________________________
ADVS Director (or designee)
Attachment Two – VDF Grantee’s Organization Information
1. Veterans Service Organization (VSO) Charter
Grantee is a VSO? Yes □ No □ If yes, chartered by:
(Chartering state or national VSO)
2. Grantee’s Form of Organization
Grantee’s Business Name:
Include: VSO post or chapter number and/or, if any, other organization designation, e.g.: Sole Proprietor / Co. / Inc. / LTD / LLC / Partnership, etc.
Street Address:
City:
State:
ZIP:
Fax:
Email:
Website:
State of Incorporation/Organization:
Date Incorporated/Organized:
Grantee is in good standing with its state of incorporation or organization? Yes □ No □
3. Grantee’s Operations
Chief Staff Officer:
Title:
Contact Person:
Title:
Contact Person’s Email:
Phone:
Grantee’s fiscal year:
From Mo/Day
To Mo/Day
Total Operating Budget:
Past Year
Current Year
Grantee’s Staff:
Paid FT
Paid PT
Volunteers
Other
Total Employees
Grantee’s EIN*:
___________________________
Federal Tax Exempt Status? Yes □ No □
*Federal Employer Tax Identification Number If no, explain why not on attachment.
Has Grantee’s governing board approved a policy, which states that the organization does not discriminate as to age, race,
religion, disability, sexual orientation, sex or national origin?
Yes □ No □ If Yes, when? ______________________
Attachment Three – Amended Statement of Service and Budget – Event, Project
or Program
1. Provide a brief description of Statement of Service provided for initial grant award.
2. Provide a detailed description of the amended Statement of Service including an explanation of why the
change is needed.
3. Provide a revised line item budget and budget narrative reflecting the change of expenditures per your
amended Statement of Service, if applicable.
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Attachment One - Certification and Authorization- Contract Amendment (Arizona)

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Completed 8 July 2022

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