COVID-19 MSA Amendment Template

Date: 
03/20/2020
Document Text Version

Member Service Agreement Amendment

 

Program Name:

 

Member Name:

 

Amendment Date:

End Date:

 

Due to the impact of COVID-19, the above-referenced member service activities will vary from those identified in the Member Service Agreement in the following ways: (Check all that apply)

 

  • Provided via Teleservice

 

  • Include grant-related activities, but activities that vary from those identified in the approved application

 

  • Include activities that are not directly related to the grant, but are related to the host site or sponsoring organizational goals

 

  • Include activities that are not directly related to the grant and are conducted in community-based organizations (not the original host site or sponsoring organization)

 

  • Include disaster response activities outside of the scope of the grant

 

In all cases, the planned activities are reviewed and approved by the Sponsoring Organization Representative to ensure that no unallowable or prohibited activities are included. To the extent possible, information about the service activities will be collected and maintained in the member file, along with verification of member service hours.

 

 

                                                                                                                                                                                           

Member Signature                                                                                                                                                                                                                                                            Date

 

 

                                                                                                                                                                                           

Sponsoring Organization Representative Signature                                                                        Printed Name, Title                                                                                   Date

 

 

Extension (if needed)

 

Due to ongoing health and public safety concerns related to COVID-19, the activities noted above have been extended to                                                              (New End Date).

 

 

                                                                                                                                                                                           

Member Signature                                                                                                                                                                                                                                                            Date

 

 

                                                                                                                                                                                           

Sponsoring Organization Representative Signature                                                                        Printed Name, Title                                                                                   Date

 

 

 

 

Printed from the website on September 21, 2020 at 10:24pm.