TA Requestor: ___________________________________________	Date: ______________ 
                              (State or local jurisdiction requesting TA)

Please describe the nature and extent of the issue or problem you are experiencing:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Catalog Title of TA Service Requested:  __________________________________________
____________________________________________________________________________

Level of Assistance: __________________________________________________________
____________________________________________________________________________

Jurisdiction Level to Receive TA:     ? State	   ? Local	    ? Both             ? Regional

Additional Information: ________________________________________________________
____________________________________________________________________________

Request is consistent with the technical assistance goals, projected needs, and priorities addressed in the statewide strategy.  

?  	Yes.  If “yes,” please list the strategy goal/objective:  _______________________________
____________________________________________________________________________

?	No.   If “no,” please attach an explanation or strategy update justifying this need for technical 		assistance or redefining goals, objectives, and priorities.

Desired Delivery Dates/Timeline: ________________________________________________

Anticipated Number of TA Participants: __________________________________________

Additional Information on Specific Needs: ________________________________________
____________________________________________________________________________

TA Requestor Point of Contact Information:

Name: _________________________________	Title: _______________________________
Phone Numbers:  ____________________________________________________________
E-mail Address:  _____________________________________________________________

___________________________________            
	SAA Authorized Signature* 			   

___________________________________            
           		      Date	
				                 
TECHNICAL ASSISTANCE (TA) REQUEST FORM


*Approval via e-mail is acceptable