WORK PLAN & BUDGET FORM Recipient Name: Address: Contact Person: Phone Number: E-mail Address: FAX Number: WORK PLAN SECTION 1. MOA #: 2. MOA Amount: 5. Subcategory Code Number, 3. MOA Term Planned Number of Clients to be Served, ____________________ $ Planned Number of Client Contacts From: _______________ Thru: a b c 4. IDENTIFIED NEED/PROBLEM, PLANNED GOAL AND SUBCATEGORY SERVICES: Subcategory Planned # Planned # Code of of Client Number Clients to Contacts be Served TRIBAL SERVICES: (NCIDC USE (Provide a Brief Description of Project Activities) ONLY) 6.A Planned Number of Volunteers # of 2.3.A Volunteers: (Enter if none.) “0” Planned Number of Volunteer Hours 6.B # of 2.3.B Volunteer (Enter if none.) “0” Hours: BUDGET SECTION OTHER FUNDS COST CATEGORY CSBG FUNDS TOTAL (If applicable) (Non-Personnel Only) TOTAL Description of Planned Expenditures: I hereby certify that this Work Plan and Budget have been reviewed and approved by the Governing Body and they do NOT include employee or travel expenses. Authorized Signature Date Printed Name & Title of Person Signing
WORK PLAN & BUDGET FORM Recipient Name: Address: Contact Person: Phone Number: E-mail Address: FAX Number: WORK PLAN SECTION 1. MOA #: ____________________ 2. MOA Amount: $ _______________ 3. MOA Term From: Thru: 5. Subcategory Code Number, Planned Number of Clients to be Served, Planned Number of Client Contacts 4. IDENTIFIED NEED/PROBLEM, PLANNED GOAL AND SUBCATEGORY SERVICES: a b c Subcategory Code Number Planned # of Clients to be Served Planned # of Client Contacts TRIBAL SERVICES: (Provide a Brief Description of Project Activities) (NCIDC USE ONLY) 6.A Planned Number of Volunteers (Enter “0” if none.) 2.3.A # of Volunteers: 6.B Planned Number of Volunteer Hours (Enter “0” if none.) 2.3.B # of Volunteer Hours: BUDGET SECTION COST CATEGORY CSBG FUNDS OTHER FUNDS (If applicable) TOTAL (Non-Personnel Only) TOTAL Description of Planned Expenditures: I hereby certify that this Work Plan and Budget have been reviewed and approved by the Governing Body and they do NOT include employee or travel expenses. Authorized Signature Date Printed Name & Title of Person Signing
15%20EZ%20WrkPln%20%26%20Bdgt%20Form.docx