"Revision Request Form" - Mississippi

Revision Request Form is a legal document that was released by the Mississippi Department of Information Technology Services - a government authority operating within Mississippi.

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Download "Revision Request Form" - Mississippi

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3771 Eastwood Drive
Jackson, Mississippi 39211
Phone 601-432-8000 Fax 601-713-6380
Revision Request
Project Title:
Stimulus (ARRA) Funds? Yes__ No __
Customer Contact Information
Agency/Institution:
Contact Person:
Address:
Phone:
Fax:
Email Address:
MAGIC Customer Number(only required from state agencies)
Division/Dept:
Provider Code:
Agency Code:
Handmail:
Yes
No
Project History and Accounting
CP-1 Number to be Revised:
Reason(s) Revision Required:
Increase Dollar Amount
Extend Expiration Date
Change Vendor Information
Increase Scope
Total Amount Authorized on CP-1 to be Revised:
Other
Project Accounting:
Expenditures to Date: Provide invoice details for at least the previous 12 months. Payments older than 12 months may be summarized by Fiscal Year
Payment History
Invoice Number
Invoice Date
Description
Invoice Amount
Payment Date
Payment Amount
CP-1 Remaining Balance:
Dollar Amount:
Expiration Date:
Original Amount Approved:
Original:
Current Balance:
New:
Amount of Increase:
New Balance:
Vendor Information
Vendor Name
Vendor Address
Original:
Original:
New:
New:
Project Scope
If the revision is due to a change in the original scope of the approved project, please describe the changes. (addition of equipment, products or services)
Other
Specify the other conditions that require this revision.
There is a charge for ITS procurement services associated with this request which will be billed to the requestor by ITS. By my signature I acknowledge
that my agency/public university is responsible for these charges/costs.
_______________________________________
___________________________________
Name (Agency Head or Public University CIO)/Title
Signature
Date
3771 Eastwood Drive
Jackson, Mississippi 39211
Phone 601-432-8000 Fax 601-713-6380
Revision Request
Project Title:
Stimulus (ARRA) Funds? Yes__ No __
Customer Contact Information
Agency/Institution:
Contact Person:
Address:
Phone:
Fax:
Email Address:
MAGIC Customer Number(only required from state agencies)
Division/Dept:
Provider Code:
Agency Code:
Handmail:
Yes
No
Project History and Accounting
CP-1 Number to be Revised:
Reason(s) Revision Required:
Increase Dollar Amount
Extend Expiration Date
Change Vendor Information
Increase Scope
Total Amount Authorized on CP-1 to be Revised:
Other
Project Accounting:
Expenditures to Date: Provide invoice details for at least the previous 12 months. Payments older than 12 months may be summarized by Fiscal Year
Payment History
Invoice Number
Invoice Date
Description
Invoice Amount
Payment Date
Payment Amount
CP-1 Remaining Balance:
Dollar Amount:
Expiration Date:
Original Amount Approved:
Original:
Current Balance:
New:
Amount of Increase:
New Balance:
Vendor Information
Vendor Name
Vendor Address
Original:
Original:
New:
New:
Project Scope
If the revision is due to a change in the original scope of the approved project, please describe the changes. (addition of equipment, products or services)
Other
Specify the other conditions that require this revision.
There is a charge for ITS procurement services associated with this request which will be billed to the requestor by ITS. By my signature I acknowledge
that my agency/public university is responsible for these charges/costs.
_______________________________________
___________________________________
Name (Agency Head or Public University CIO)/Title
Signature
Date