Budget Amendment Request

Please note that the request form below will need to be submitted for each budget amendment.

Organization Name:

Federal Tax ID#: (Only include numbers)

Project Contact Name:

Contact's Title:

Contact's Phone Number:

Contact's Email Address:

Enter the dollar amount of the budget that you would like to amend:

Name and describe the activity that was originally approved (i.e., the original purpose for which the funds were to be used):

Name and describe the amended activity for which you wish to spend the funds:

Describe how the amended activity falls within the approved remediation uses set forth by the TN Opioid Abatement Council:

Click here for the TN Opioid Abatement Council approved remediation uses.

Please note that by submitting this form, you acknowledge that all information provided is accurate to the best of your knowledge, and you are providing your electronic signature as confirmation of your approval and authorization for this request.