OSHS CA BV OSHS Cooperative Agreement Budget Variance Request Form

OSHS COOPERATIVE AGREEMENT BUDGET VARIANCE REQUEST FORM
1.

Fill in the “FEDERAL TOTAL” and “NON-FEDERAL TOTAL” columns of this form from Section C and D of the current OSHS BIF in the Cooperative
Agreement (CA).

2.

Insert the revised budget figures in the “REVISED FEDERAL TOTAL” and “REVISED NON-FEDERAL TOTAL” columns. The total amount of the revision
cannot exceed 4.0% of the total CA amount. Any budget variance request must move equal amounts of federal OSHS funding and state matching funds. All
amounts should be entered in dollars and cents.

3.

Enter the “FEDERAL PAYMENTS TO DATE” for each program for which a variance is requested. No single program’s “REVISED FEDERAL TOTAL” can
be lower than the total “FEDERAL PAYMENTS TO DATE” for the program.

4.

Forward the form to the regional office for review no later than 60 days after the end of the fiscal year. Regional offices will send Budget Variance Requests to
the national office no later than 15 days after receipt from state agencies. Variance requests must be processed prior to the submission of closeout materials.

We estimate that it will take an average of 15 minutes to complete this form including time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the information. Your response is required to obtain or
retain benefits under 29 USC 673. If you have any comments regarding these estimates or any other aspect of this form, including suggestions
for reducing this burden, send them to [email protected]. You are not required to respond to the collection of information unless it
displays a currently valid OMB control number.

PROGRAM

FEDERAL
TOTAL

NONFEDERAL
TOTAL

REVISED
FEDERAL
TOTAL

REVISED
NONFEDERAL
TOTAL

FEDERAL
PAYMENTS
TO DATE

OMB No.1220-0149
Approval Expires
06-30-2024

VARIANCE

SOII

$ 0.00

CFOI

$ 0.00

Subtotal

$ 0.00

$ 0.00

$ 0.00

$ 0.00

$ 0.00

$ 0.00

SOII-AAMC

$ 0.00

CFOI-AAMC

$ 0.00

Subtotal

$ 0.00

$ 0.00

$ 0.00

$ 0.00

$ 0.00

$ 0.00

TOTAL

$ 0.00

$ 0.00

$ 0.00

$ 0.00

$ 0.00

$ 0.00

State Agency Name:

OSHS CA No.:

Requested by:
Signature:

Date:

Regional Office Review
Variance Requested:

$ 0.00 Percent of Total CA:

Reviewed by:

Date:

Approved by:

Date:

OSHS CA BV Request Form (Revised June 2023)

0.00%