Professional Documents
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*
ROBERT F. GOLLNICK
~:; " (l ~4 STATE CAMPUS
BUILDING 12, ROOM 166
ANN MARIE TALIERCIQ
CARLJ. THURNAU
ALBANY. NEW YORK 12240 Members
ROBERT F. CARPENTER (5181457 -7629
Chairman FAX (5181465.6082
Your contract number C010397 for the 2003/2004 aSH T&E grant has
been approved for modific ' . e Department of Labor.
Attach ~re six (6) copies of Appendix X 'aQd two complete modifications.
NOTE: It is now tne-Depactment of Labor's policy to send just the changed pages
to the contractor for sign ture. Please have each Appendix X, Informal
Modification Signature Sti et, signed in blue ink and notarized. Please return the
entire package at your earli st convenience ,
Sincerely,
oe~hai~.~
rd
'J'
Grant Manager
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Vi(tL
Attachments 2{ /3/() 't
GOVERNMENT
EXHIBIT
GD -30
Formal Modification
NEW YORK STATE
DEPARTMENT OF LABOR Charity Registration #
_Exempt 9 _
APPENDIX X
This is an AGREEMENT between THE STATE OF NEW YO~ acting by and through the Department
of Labor, having its principal office at State Office Building Campus, Building l2, Albany, New York (herein
referred to as the STATE,) and _Teamsters Local 294 (hereinafter referred to as the
CONTRACTOR), for modification of Contract Number _COI0397 , as set forth in attached
Appendix B (Project Budget and Program Narrative Addendum), which is hereby incorporated by reference.
This contract shall be for the period_August 1, 2003__ through_July 31, 2004 _
This contract may be extended up to four years through ----_
If Not for Profit: Contractor has ~ has not 0 timely filed with the Attorney General's Charities Bureau
all required periodic or annual written reports.
All other provisions of said AGREKMENT shall remain in full force and effect.
IN WITNESS THEREOF, the parties hereto have executed or approved this AGREEMENT as of the dates
appearing under their signatures.
ili 10 AQ 14)
o
C"\.crBco
resides at
I
S'-o QlYnl>'-Q A l> 294 the corporation described herein which executed the foregoing instrument; and that
be/she signed his/her name thereto by authority of the Board of Directors of said corporation.
NYSDOL
Liaison: Linsay M. Baird Phone: 518-457-6670
Address: NYSDOUOSH T&E Fax: 518-485-6082
State Office Campus Bid 12 Rm 166 E-Mail: usaaab@Labor.State.NY .US
Albany, NY 12240
Submittal: FY 2003·2004
Original _
Mod # 1 X Increases Funding From : 55,800 .00 to 69,300 .00
Decreases Funding From : to
Changes End Date From :
----- to
-----
Funding Source: 8/1/03 7/31/04
Program: $69,300
Budget
1. Staff Salaries
2. Staff Frin e Benefits
3. Contracted Services
4. Other Costs
5. Total Contract Costs
6. Total Match Costs