No Cost Extension Form 
 
Legal Applicant Name:				________
Program Name:					________ 
Program Year:					________       
Person Submitting Request:			________       
Date:			____________________________       
 
1.	PURPOSE: Please provide a brief summary of why the program is requesting a no cost extension. If this request is due to an approved program design change, please include detailed information describing those changes.  

2.	DATE CHANGE:  
A.	What is the original budget period end date of your grant?

B.	What is the proposed new budget period end date of your grant? 

3.	BUDGET: Are there any significant budget adjustments that need to be made because of this request?  
No budget adjustments are needed for this request. 
Yes, budget adjustments are needed for this request; a description is included:       

CERTIFICATION  
I understand that performing the work of two different grant awards concurrently requires special reporting to ensure all expenditures and in-kind match are allocated in accordance with the relative benefit received by each grant award.  When costs that directly benefit the AmeriCorps grants are not readily attributable to one grant or the other, this requirement includes using an appropriate allocation method to distribute these shared costs between the two grants.   
 
I certify that the information submitted in this request is accurate and officially request a no-cost extension for the AmeriCorps program. 
 
ENSURE THAT THE FOLLOWING DOCUMENTS ARE ATTACHED: 
•	Member Information Form (For each member that will require an extension to complete service) 

Name of Authorized Signatory:								       

Authorized Signature:									 
 
Mail or scan and email a signed copy of your request to the attention of your primary contact at Nevada Volunteers. 
 
MEMBER INFORMATION FORM 
 
Complete one form for each member for whom the extension is being requested.  
 
NOTE: If this change is an approved program design change affecting your entire Member Corps, you do not need to fill out this form. Please provide detailed information on the program change in the PURPOSE section (question 1) of the No Cost Extension Request Form.  
 
Member Name:					__________
Member Type:					__________			
Current Start Date: _________________________________ 
Current End Date: __________________________________
Requested End Date for Member:       	__________
 
1.	Has the Member Been Suspended?  
No  
Yes (if yes, number of days in suspension      	___) 

2.	Hours of service completed as of the date of the request: ____________      

CERTIFICATION 
 
Prior to submitting this request, our program: 
  
•	Assessed the member’s interest/commitment to completing the program 
•	Communicated to the member the new end date for service completion
o	Weekly hour requirement of Number of Hours until New Requested End Date 
•	Communicated to the member that they: 
o	Will not be receiving a living allowance after their original end date; OR 
o	Will continue to receive a living allowance in the amount of $___________.
_____________________ (how often: weekly, monthly, biweekly) with the final payment to be received on ____________________________ (date). 

 If the No Cost Extension is approved, I certify the following for each member: 
 
•	Amendment to the member service agreement detailing the new term of service including: 
o	New End Date; 
o	Weekly Hours Goal;  
o	Living Allowance amount (in-line with current living allowance distribution requirements) or signed statement that no living allowance will be earned beyond the original end date; 
o	Information on benefits; 
o	Discipline plan for members not meeting the expected hour requirement; and 
o	Clear statement detailing repercussions of exiting early for cause. (By choosing to exit, members give up their loan forbearance/interest payment, as well as the education award and forfeit one term of member service).
 
I have developed a plan to ensure that this member is provided with adequate supervision until the completion of their term of service which may include a new agreement with site supervisor/host site. 
 
I understand that I cannot enter into an agreement with a member to change their end date beyond the budget period end date on our grant award from Nevada Volunteers until I have received approval from Nevada Volunteers granting the No Cost Extension. 
 
I understand that signed member agreements will be reviewed during on-site Member File Review. 
 
I also understand that, according to the AmeriCorps Provisions, full-time members who are eligible to receive health care benefits must be offered such, and all members must be provided with Workers’ Compensation; our program will adhere to these requirements. 
 
I certify that the information submitted in this request is accurate and officially request a No-Cost Extension for the AmeriCorps program. 
 
Name of Authorized Signatory:						
  
Authorized Signature:							 
 
Date: 				_________________________________