Form SFN52679 "Esg/Ndhg Request for Amendment" - North Dakota

What Is Form SFN52679?

This is a legal form that was released by the North Dakota Department of Commerce - a government authority operating within North Dakota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2016;
  • The latest edition provided by the North Dakota Department of Commerce;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form SFN52679 by clicking the link below or browse more documents and templates provided by the North Dakota Department of Commerce.

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Download Form SFN52679 "Esg/Ndhg Request for Amendment" - North Dakota

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ESG/NDHG REQUEST FOR AMENDMENT
NORTH DAKOTA DEPARTMENT OF COMMERCE
NORTH DAKOTA DIVISION OF COMMUNITY SERVICES
SFN 52679 (8/16)
1. Recipient Name
Address
City
State
ZIP Code
Phone Number
2. Instrument Number
3. Amendment Number
4. Approved Grant Period
5. Date of Request
6. Type of Amendment
A.
Budget Revisions
B.
Extension of Time
Extension Revised Date
7. Explanation for Request (Attach Additional Page if Necessary)
Approved
Match
Revised DCS
Match Funds
Total
Activity
DCS Budget
Funds
Budget
Revised
Budget
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
Total Revision (+/-)
0.00
0.00
Total Budget
0.00
0.00
0.00
0.00
8. Submitted By: (Executive Director)
9. Action Taken (DCS USE ONLY)
Approved 
Disapproved 
Signature
Signature
Name
Name
Title
Title
Date
Date
ESG/NDHG REQUEST FOR AMENDMENT
NORTH DAKOTA DEPARTMENT OF COMMERCE
NORTH DAKOTA DIVISION OF COMMUNITY SERVICES
SFN 52679 (8/16)
1. Recipient Name
Address
City
State
ZIP Code
Phone Number
2. Instrument Number
3. Amendment Number
4. Approved Grant Period
5. Date of Request
6. Type of Amendment
A.
Budget Revisions
B.
Extension of Time
Extension Revised Date
7. Explanation for Request (Attach Additional Page if Necessary)
Approved
Match
Revised DCS
Match Funds
Total
Activity
DCS Budget
Funds
Budget
Revised
Budget
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
Total Revision (+/-)
0.00
0.00
Total Budget
0.00
0.00
0.00
0.00
8. Submitted By: (Executive Director)
9. Action Taken (DCS USE ONLY)
Approved 
Disapproved 
Signature
Signature
Name
Name
Title
Title
Date
Date
REQUEST FOR AMENDMENT DIRECTIONS
Block 1:
Enter the official mailing address and phone number of the grantee.
Block 2:
Enter the DCS assigned Instrument Number on the Financial Award.
Block 3:
Amendment requests are to be numerically accounted for locally. Indicate the appropriate
request number.
Block 4:
Enter the Approved Budget/Project Period from the Financial Award.
Block 5:
Enter date of the preparation of the Request for Amendment.
Block 6:
Place a mark in the appropriate space to reflect the type of amendment being requested.
Only fill in Extension Revised Date if requesting an Extension of Time.
Block 7:
Provide a detailed explanation of the amendment, to include the reason and the results.
Enter activities funded on award. Enter amount awarded for each activity funded. In the
Revised DCS Budget column, enter +/- for each activity amending. Total Budget column
automatically calculates. Approved DCS Budget should equal Total Budget unless
amending for more or less dollars.
Block 8:
Enter the name and title of the Executive Director. This is the individual who signed the
Financial Award.
Block 9:
For DCS use only.
Send original signed document to:
ND Department of Commerce (DCS)
1600 East Century Avenue, Suite 2
PO Box 2057
Bismarck, ND 58502-2057
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