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Agency Name: <br />North Carolina Department of Health and Human Services <br />Division of Public Health <br />DPH Budget Contract Unit <br />WIC PROGRAM <br />Lee County Health Department <br />Original <br />5403 Client Services <br />5404 Nutrition Education <br />(Minimum Amount $ ) <br />5405 General Administration <br />(Maximum Amount $ ) <br />5409 Breastfeeding Promotion <br />(Minimum Amount $ ) <br />Total <br />Amount <br />$3,802 <br />$3,802 <br />Instructions for completing the original budget: <br />Revision # _ <br />Revision applies to: <br />Attachment B-1 <br />00063 <br />SFY allocation (June - Sept.) <br />FFY allocation (Oct. -May) <br />STATE USE ONLY <br />FRC FRC <br />Using the funds listed under total above, allocate your funds among the four WIC activities. Note the minimum level <br />of funds that must be budgeted for Nutrition Education and Breastfeeding Promotion, and the maximum amount of <br />funds to be budgeted in General Administration. Your total for the four activities should match the total on the <br />Budgetary Estimate. This form is to be signed and returned with the WIC Agreement Addenda to the Division's <br />Contract Unit. <br />Instructions for completing budget revisions: <br />This form may be reproduced and used to submit budget revisions. When submitting budget revisions, show the amount of funds <br />being increased/decreased in the amount column for the respective activity (ex. +1000 or -1000). Line through the total amount <br />and put a zero. Indicate the Revision #. Budget revisions are due in the program office by May 1st for close-out of the state fiscal <br />year and September 1st for close-out of the federal fiscal year. This form should be mailed to the WIC Operations Manager, <br />1914 Mail Service Center, Raleigh, NC 27699-1914. <br />Signature of Local Agency Director <br />Signature of Local Finance Officer <br />Signature of State WIC Operations Manager <br />Date <br />Date <br />Date <br />