Form FEMA Form 089-12 FEMA Form 089-12 Extensions/Budget Changes

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

URBAN SEARCH RESCUE RESPONSE SYSTEM
BUDGET CHANGE FORM
Paperwork Burden Disclosure Notice
Public reporting burden for this form is estimated to be 1 hour per response. The burden estimate includes the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and submitting the form. You are not required to respond to this
collection of information unless it displays a valid OMB Number. Send comments regarding the accuracy of this burden estimate and any suggestions for
reducing the burden to: Collections and Research Branch, Department of Homeland Security, Federal Emergency Management Agency, 1800 South
Bell Street, Arlington, VA 20590-3305, Paperwork Reduction Project (1660-0073). Note: Do not send your completed form to this address.

INSTRUCTIONS
CURRENT BUDGET PLAN INFORMATION - List those items in your Task Force's original Spend Plan/Budget Narrative for the appropriate Cooperative
Agreement that were overestimated or never completed/needed.
- Description of work not being accomplished - the item(s) your Task Force had in their budget for the Cooperative Agreement year referenced
on the top of the sheet. These are items that were, for one reason or another, never accomplished (overtaken by other events?) or maybe
the cost to complete the work was overestimated. Present a solid reason for this change/these changes.
- Reason - provide the reason for why these funds were not expended on what was originally planned. Address circumstances beyond your
control that causes the need for the change.
- Anticipated Cost - the original cost listed in your Spend Plan for that particular item/service.
- Program Category/Object Class - one of the 4 main categories - Training, Equipment, Management, or Storage/Maintenance.
- Included in the Original Budget Submission? - the answer should be "YES" because that is the point of the first section of this form - to
outline those items you had originally planned to do in the original Spend Plan.
REQUESTED BUDGET REVISION - list the item(s) you now wish to purchase using the funding that is now available.
- Description of Modified Budget Item - brief description of what you now want to purchase.
- Reason modified budget item is required - why do you need it now? Include that it would have been advantageous to have it before but
are now able to purchase. Must show the item was needed during the Cooperative Agreement year being addressed.
- Projected Cost - how much do you anticipate this item will cost?
- Program Category/Object Class - see above for categories. The funds should be moved to a category that is most appropriate for this
new purchase.
- SOW Authority - review the Statement of Work for the applicable CA and reference the section(s) this new item is directly or indirectly tied
to (e.g., FY2005 SOW Article VI, Section A, Item 3)
*The TOTAL REVISED BUDGET REQUIREMENTS should NOT exceed the TOTAL FUNDS REMAINING.
** Also need to include revised FF20-20 with budget submission
*** For requests that include vehicle purchase(s), please include specifications for all rolling cache (e.g., vehicles, gators, trailers).

FEMA Form 089-12

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TASK FORCE

AWARD #

CURRENT BUDGET PLAN INFORMATION
Description of work
not being
accomplished

Reason

Anticipated
Cost

Program
Category/
Object Class

Included in original Budget
Submission? (Answer
should be YES)

Program
Category/
Object Class

SOW Authority
(e.g, FY05 SOW,
Article 5, Sec. C, 2)

TOTAL FUNDS REMAINING

REQUESTED BUDGET REVISION
Description of
modified
budget item

Reason modified budget item
is required

Projected Cost

TOTAL REVISED BUDGET REQUIREMENTS

**TOTAL FUNDS REMAINING
TOTAL REVISED BUDGET REQUIREMENTS
Note: Revised budget requirements
should NOT exceed total funds remaining

**Also need to include revised FF20-20 with budget change submission
***For requests that include vehicle purchase(s), please include specifications for the vehicle(s)
FEMA Form 089-12

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SAMPLE
AWARD #

TASK FORCE
CA-TFX

EMW-2005-CA-XXXX

CURRENT BUDGET PLAN INFORMATION
Description of work
not being
accomplished

Reason

Anticipated
Cost

Program
Category/
Object Class

Included in original Budget
Submission? (Answer
should be YES)

Mobilization Exercise

Activation during Cooperative Agreement period of
performance. This meets the Statement of Work
Requirements

$20,000

Training

YES

Shoring Training

Training Requirements were met as stated in the
SOW/CA however it was funded by State and at no
cost to the US&R Cooperative Agreement

$5,000

Training

YES

Salaries and Expenses

Did not fill administrative position until mid-way
through the Cooperative Agreement period. Until
that time, no acceptable applicant applied

$50,000

Admin

YES

TOTAL FUNDS REMAINING

$75,000

REQUESTED BUDGET REVISION
Description of
modified
budget item

Reason modified budget item
is required

Projected
Cost

Program
Category/
Object Class

SOW Authority
(e.g, FY05 SOW,
Article 5, Sec. C, 2)

150 Sets Cold Weather Gear
(LG-0122.00)

Had the need but did not have sufficient funding in the
FY-05 grant and have a need for the 150 sets.

$70,000

Equipment

FY05 SOW
Sec VI-C, 1

WMD Awareness Training Feb/March 2007

It has been since 2003 that a full WMD Awareness
Training has been held, with new members on the team,
this will get them qualified.

$5,000

Training

FY05 SOW,
Sec VI-B, 2

TOTAL REVISED BUDGET REQUIREMENTS

$75,000

**TOTAL FUNDS REMAINING

$75,000

TOTAL REVISED BUDGET REQUIREMENTS
Note: Revised budget requirements
should NOT exceed total funds reminig

$75,000

**Also need to include revised FF20-20 with budget change submission
***For requests that include vehicle purchase(s), please include specifications for the vehicle(s)
FEMA Form 089-12

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COOPERATIVE AGREEMENT EXTENSION FORM
TASK FORCE

AWARD #

PROGRAM MANAGER

PHONE #

Current Period of Performance

Requested Period of Performance

From

From

To:

Type of Extension

To:

Budget change? (If YES, also submit Budget Change Form)

1st Extension of 12 Months or Less

2nd Extension

YES

1st Extension Exceeding 12 Months

3rd Extension

NO

BRIEF STATUS OF ONGOING ACTIVITY UNDER THIS COOPERATIVE AGREEMENT

EXPLANATION OF WHY ACTIVITY COULD NOT BE COMPLETED WITHIN THE PERIOD OF PERFORMANCE. (Include actions taken to resolve
any problems, how these circumstances were/are beyond your control, and justification for the new date)

FOR FEMA USE ONLY
US&R Program Office
APPROVE

Name & Signature of Program Office Official

DISAPPROVE
Grants Management
APPROVE

Name & Signature of Grants Management Official

DISAPPROVE
FOR 2ND APPROVALS ONLY
US&R Program Office Branch Chief
APPROVE

Name & Signature of Program Branch Chief

DISAPPROVE
Grants Management Section Chief
APPROVE

Name & Signature of Grants Management Section Chief

DISAPPROVE

FEMA Form 089-12

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