Spreadsheet: 10e81dfe-85cc-4a09-9176-926011ab846c
Sheet: Sample Budget Revision Form

 | Colorado Department of Public Health and Environment PREVENTION SERVICES DIVISION- BUDGET REVISION FORM
 |  |  |  |  |  | Reason for Budget Revision:
 |  |  |  |  |  | Budget changed more than 25%
 | SAMPLE BUDGET
 | [NAME] | ABC Health Center |  | Program Contact Name, Title, Phone and [NAME] |  | [NAME], Executive Director, [PHONE], [EMAIL]
 | Contract Period | 7/1/13 - 6/30/14 |  | Fiscal Contact Name, Title, Phone and [NAME] |  | [NAME], Finance Director, [PHONE], [EMAIL]
 | Contract/Encumbrance Number | PO FLA PPG1300045 (SAMPLE NUMBER) |  | Project Name |  | Caring for Seniors Project
 |  |  |  | Effective Date of Budget Revision |  | 2013-04-01 00:00:00
 | Expenditure Categories
 | Personal Services |  |  |  |  |  | ORIGINAL BUDGET | REVISED BUDGET | [NAME]
 | Position Title/              Employee Name | Justification for Revision
 | Executive Director, [NAME] | Will be providing additional oversight of project (.75 FTE) due to additional requirements for project for the last nine months |  |  |  |  | 15732 | 28822.5
 | Finance Director, [NAME] | Savings for this staff member as administrative assistant was trained to prepare invoices - for six months of project |  |  |  |  | 8784 | 7596
 | Administrative Assistant, [NAME] (PT [NAME] employee) | Administrative and billing support ($15 x 20 hours/weeks for 40 weeks for 100% of time) |  |  |  |  | 10800
 | Accountant, [NAME] | Discount for accounting services |  |  |  |  | 8000 | 6700
 | Total Personal Services (including fringe benefits)
 | Supplies & Operating Expenses |  |  |  |  |  | ORIGINAL BUDGET | REVISED BUDGET | [NAME]
 | Item | Justification for Revision
 | Telephone |  |  |  |  |  | 225 | 225
 | Public education visual aids | In-Kind donation from printing company |  |  |  |  | 500 | 400
 | Postage |  |  |  |  |  | 125 | 125
 | Copying/Printing | In-Kind donation from printing company |  |  |  |  | 750 | 298
 | Office supplies | Reduction in expense of office supplies |  |  |  |  | 110 | 50
 | Internet |  |  |  |  |  | 269.91 | 269.91
 | Total Supplies & Operating Expenses
 | Travel |  |  |  |  |  | ORIGINAL BUDGET | REVISED BUDGET | [NAME]
 | Item | Justification for Revision
 | Mileage |  |  |  |  |  | 13.75 | 13.75
 | Lodging |  |  |  |  |  | 200 | 200
 | Per Diem |  |  |  |  |  | 80 | 80
 | Total Travel Expenses
 | Contractual (payments to third parties or entities) |  |  |  |  |  | ORIGINAL BUDGET | REVISED BUDGET | [NAME]
 | Item | Justification for Revision
 | Consultant | The consultant costs have increased due to additional requirements in project. |  |  |  |  | 5000 | 6000
 | Total Contractual Expenses
 | SUB-TOTAL BEFORE INDIRECT
 | Indirect |  |  |  |  |  | ORIGINAL BUDGET | REVISED BUDGET | [NAME]
 | Item | Justification for Revision
 | Negotiated Indirect cost rate (Federal, state, or CDPHE) | 26 % of Total Direct Costs
 | Indirect (other) | Less Equipment (meaning 0% can be charged on these line items)
 | Indirect (modified or additional base) | 2% of Subcontracts
 | Total Indirect
 | TOTAL OF ALL EXPENDITURE CATEGORIES
 | TOTAL [NAME] EQUAL ZERO
 | Signature of Authorizing Agency Representative:_________________________________________________________            TITLE:  ____________________________________
 | DATED:________________________
 | CDPHE USE ONLY:
 | THE BUDGET REVISION HAS BEEN APPROVED:
 | Signature of PROGRAM MANAGER:_________________________________________________              DATED:____________________
 | Signature of PROGRAM FISCAL OFFICER:___________________________________________              DATED:_____________________
 | Indirect (modified or additional base)
 | THE BUDGET REVISION HAS BEEN DENIED FOR THE FOLLOWING REASON(S):
 | SAMPLE BUDGET