Form FEMA Form 089-0-12 FEMA Form 089-0-12 Urban Search and Rescue Amendment Form

Department of Homeland Security
Federal Emergency Management Agency

OMB 1660-0073

URBAN SEARCH AND RESCUE RESPONSE SYSTEM

Expires July 31, 2012

AMENDMENT FORM
Paperwork Burden Disclosure Notice
Public reporting burdern 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 is 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
FOR SCOPE OF WORK/BUDGET CHANGE REQUESTS:
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’ve been advantageous to
have it before but are now able to purchase. Must show the item was needed during the Cooperative Agreement year
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., "FY2011 US&R Guidance, Part VIII, Section VIII.A.6")
*If modified budget item is a vehicle purchase, please include specifications.
**Need to include revised SF424A with scope of work/budget change submission
FOR PERIOD OF PERFORMANCE CHANGE/EXTENSION REQUESTS:
Fill out form as directed, providing reason an extension request is necessary and the particular circumstances beyond your control
that lead to this request.

SUBMIT THROUGH THE ND GRANTS SYSTEM. UPLOAD REQUEST AND ALL ATTACHMENTS TO THE REQUEST.

FEMA Form 089-0-12

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SCOPE OF WORK/BUDGET CHANGE REQUEST - continuation

REQUESTED BUDGET REVISION

CURRENT BUDGET PLAN INFORMATION

TASK FORCE:
AWARD #:

Description of work not being
accomplished

REASON

TOTAL FUNDS REMAINING:

Description of modified budget
item

Reason modified budget item is required

Anticipated
Cost

Program
Category/Object
Class

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

$0
Program
Category/Object
Projected Cost
Class

TOTAL REVISED BUDGET REQUIREMENTS:

$0

**TOTAL FUNDS REMAINING:
TOTAL REVISED BUDGET REQUIREMENTS:
(NOTE: Revised budget requirements should NOT exceed total
funds remaining)
**Also need to include revised SF-424A with budget change submission

$0
$0

SOW
Authority

For request that include vehicle purchase(s), please include specifications for the vehicle(s)
Name and signature of US&R Task Force Requesting Official
FEMA Form 089-0-12

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Cooperative Agreement Extension Form - continuation

TASK FORCE:
AWARD NUMBER:
Program Manager:
Phone #:
Current Period of Performance:
Requested Period of Performance:

to
to

TYPE OF EXTENSION:
1st Extension of 12 months or Less
1st Extension exceeding 12 months
2nd Extension
3rd Extension
BUDGET CHANGE?
YES
NO
(if YES, also submit Budget Change Form)
BRIEF STATUS OF ONGOING ACTIVITY UNDER THIS COOPERATIVE AGREEMENT:

OUTLINE OF REMAINING FUNDS AVAILABLE AND NECESSARY TO FINISH ACTIVITY DURING EXTENSION:

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 of the new date)

Name and signature of US&R Task Force Requesting Official

FEMA Form 089-0-12

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