Print the form and complete as follows:

1. Fill in effective date: This is the date the Fund-Program-Org code is to become active or current date if immediate.
   
   
2. Check one of the four reasons (in bold) for the request and any items listed below the checked item.
   
   
   1. Request for change in Fund-Program-Org code name
      include the Fund-Program-Org to be changed and state the new name of the Org
      
      
   2. Request for change in authorized signature
      include the Fund-Program-Org code to be changed, include all requested authorized signers. (When multiple signers, designate if all need to sign by including 'and' between names or if either can sign by including 'or' between names).
      
      
   3. Request to close out a Fund-Program-Org code
      include Fund-Program-Org to be closed include necessary forms to close out any remaining revenue, expenditure or cash balances.
      
      
   4. Request for a new Fund-Program-Org code
      complete all fields as indicated below:
      
      
      • Describe proposed use of the Org and the reason it is necessary:
        The need for the new Fund-Program-Org must either be a new program, a new grant, or of a significant dollar or transaction amounts that separate recording and reporting is necessary. All requests will be reviewed based on the information supplied with the request form to determine if a new Org is needed or if the activity can be combined with an established Fund-Program-Org.
        
        
      • Source of Funding:
        This determines the Fund assigned to the Org. Is it GPR funds, a Federal grant or non-federal grant, a gift, or program revenue? Be specific as to the source of the funds. Include a complete statement of how revenue will be generated and how rates were determined.
        
        
      • Fund-Program-Org Name:
        Use a name that is an indication of its use so it is easily recognized.
        
        
      • Include all authorized signers:
        Include all names that can sign for expenditures. Include whether all need to sign by including 'and' between the names, or if either can sign include 'or' between the names.
        
        
      • Project period of Fund-Program-Org:
        If Org is to be kept open for a certain period of time, include those dates. If there is no set time period, leave this field blank.
        
        
      • Manager name:
        Person responsible for monitoring Org for proper activity . Also include the appropriate department.
        
        
      • If this is a fund 128 Org, include the Auxiliary report number
        the code is to be added to. (If unsure, contact Mike Cohen @ 1925).
        Fund 128 interest earnings. (If unsure, contact Mike Cohen.)
        
   
   
3. Signature of Requester: Person requesting the new Fund-Program-Org
   
   
4. Signature of Division Budget contact:
   
   

   Chancellor's Division:	Randy Marnocha, Hyer Hall 301
   Academic Affairs:	Randy Marnocha, Hyer Hall 301
   Administrative Affairs:	Jim Freer, Hyer Hall 330
   Student Affairs:	Steve Summers, Hyer Hall 205

   
   
   

Once the form is signed by the Division Budget Contact, make a copy to keep and submit the original to Nancy Cohen, Financial Services, Hyer Hall 110. A copy will be returned when all activity has been completed by Financial Services.