Action Plan / Techinal Assistance Request

<Grantee Name> <Grantee Mailing Address> EIN - <#>	<Principal Grantee Contact > <Month/Day/Year>
Part I: Action Plan
Action Item:	Target Completion Date:
Expected Outcome:

Key Steps	Timeframe	Responsible Party	Status	Bureau

Transition Date to Grant Application:

Additional Comments:

Action Plan / Techinal Assistance Request

<Grantee Name> <Grantee Mailing Address> EIN - <#>	<Principal Grantee Contact > <Month/Day/Year>

Part II: Technical Assistance Request

Section I: To be Completed by Grantee:

Summary of TA Request:

Expected Outcome:

Estimated Number of Days:

Section II: To be Completed by OPR:

Region:
Team Lead:
Grant #:
Bureau/Office Funded:
Project Officer:
OPR Review Team Concurrence with Request:
OPR Comments:
Project Officer Comments:
Recommendation Bureau/Office to Lead TA: