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

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Overview

Instructions-Amendment Req
SOW-Budget Change Req
POP-Extension Req

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Sheet 1: Instructions-Amendment Req

Department of Homeland Security

Federal Emergency Management Agency

OMB 1660-0073

URBAN SEARCH AND RESCUE RESPONSE SYSTEM

Expires: 11/30/2015

AMENDMENT FORM

PAPERWORK BURDEN DISCLOSURE NOTICE FEMA Form 089-0-12

Public reporting burden for this data collection is estimated to average 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 this form. This collection of information is required to obtain or retain benefits. You are not required to respond to this collection of information unless a valid OMB control number is displayed on this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW., Washington, DC 20472-3100, 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 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., "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.

<FOR ALL AMENDMENT REQUESTS> SUBMIT THROUGH THE ND GRANTS SYSTEM. UPLOAD REQUEST AND ALL ATTACHMENTS TO THE REQUEST.

FEMA Form 089-0-12

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Sheet 2: SOW-Budget Change Req

SCOPE OF WORK/BUDGET CHANGE REQUEST - continuation
	TASK FORCE:
	AWARD #:
	Description of work not being accomplished	REASON	Anticipated Cost	Program Category/Object Class	Included in original Budget Submission? (answer should be YES)
CURRENT BUDGET PLAN INFORMATION
		TOTAL FUNDS REMAINING:	$0
REQUESTED BUDGET REVISION	Description of modified budget item	Reason modified budget item is required	Projected Cost	Program Category/Object Class	e.g., FY05 SOW, Article 5, Sec. C, 2 SOW Authority
		TOTAL REVISED BUDGET REQUIREMENTS:	$0
		**TOTAL FUNDS REMAINING:	$0
		TOTAL REVISED BUDGET REQUIREMENTS:	$0
		(NOTE: Revised budget requirements should NOT exceed total funds remaining)
	**Also need to include revised SF-424A with budget change submission
	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								Page 2 of 3

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Sheet 3: POP-Extension Req

Cooperative Agreement Extension Form - continuation

TASK FORCE:

AWARD NUMBER:

Program Manager:

Phone #:

Current Period of Performance:

to

Requested Period of Performance:

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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