Look-Alike Annual Certification Sample Budget Narrative

This sample line-item budget narrative is a broad outline of what to include in a Health Center Program look-alike Annual Certification submission. We require a detailed budget narrative for all items within each category.

Revenue

(Totals should be consistent with information presented in the SF-424A and Form 3: Income Analysis)

REVENUE	CERTIFICATION PERIOD AMOUNT
APPLICANT ORGANIZATION
STATE FUNDS
LOCAL FUNDS
OTHER SUPPORT
PROGRAM INCOME (fees, third party reimbursements, and payments generated from the projected delivery of services)
TOTAL REVENUE

Expenses

Object class totals should be consistent with those presented in Form 3A: Look-Alike Budget Information.

PERSONNEL	CERTIFICATION PERIOD AMOUNT
ADMINISTRATION
MEDICAL STAFF
DENTAL STAFF
BEHAVIORAL HEALTH STAFF
MENTAL HEALTH SERVICES
SUBSTANCE USE DISORDER SERVICES
VISION SERVICE
ENABLING STAFF
TOTAL PERSONNEL

 

FRINGE BENEFITS	CERTIFCATION PERIOD AMOUNT
FICA @ X.XX%
Medical @ X%
Retirement @ X%
Dental @ X%
Unemployment & Workers Compensation @ X%
Disability @ X%
TOTAL FRINGE @ X%

 

TRAVEL	CERTIFICATION PERIOD AMOUNT
Patient travel: $X x X,XXX uninsured visits and enabling service appointments
Provider Training: 2 trainings in QI/QA @ $X per person x 2 FTEs 5 hotel nights @ $X per night x 2 FTEs x 2 trainings
Outreach (X,XXX miles @ $0.XX per mile)
TOTAL TRAVEL

 

EQUIPMENT (Include items of moveable equipment that cost $5,000 or more and with a useful life of one year or more.)	CERTIFICATION PERIOD AMOUNT
Ultrasound machine
3 dental chairs @ $X,XXX each
TOTAL EQUIPMENT

 

SUPPLIES (Include equipment items that cost less than $5,000 each and other supplies.)	CERTIFICATION PERIOD AMOUNT
4 laptop computers @ $X each
Office Supplies ($X per month x 12 months)
Printing Costs ($X.XX per brochure x 4 brochures x X,000 copies)
Medical Supplies ($X.XX per visit x X,XXX visits)
Dental Supplies ($X.XX per visit x X,XXX visits)
TOTAL SUPPLIES

 

CONTRACTUAL (Include detailed justification.)	CERTIFICATION PERIOD AMOUNT
Pharmacy Services ($X per contract)
Laboratory Services ($X per sample x X,XXX samples)
Housekeeping Services ($X per month x 12 months)
Optometry Services ($X per patient x XXX patients)
Waste Removal ($X per month x 12 months)
TOTAL CONTRACTUAL

 

OTHER (Include detailed justification.)	CERTIFICATION PERIOD AMOUNT
EHR provider licenses $X each
Staff Recruitment – newspaper and Internet posting
Audit Services with HIJ Firm
Membership Dues (specify membership organization and cost per each)
Property Insurance
Repairs and Maintenance - not covered by warranty ($X per month x 12 months)
Rent ($X per month x 12 months)
Subaward for
TOTAL OTHER
TOTAL DIRECT CHARGES (Sum of TOTAL Expenses)

 

INDIRECT CHARGES (Include approved indirect cost agreement.)	CERTIFICATION PERIOD AMOUNT
X% indirect cost rate (includes utilities and accounting services)
TOTALS (Total of TOTAL DIRECT CHARGES and INDIRECT CHARGES)

Additional Budget Justification

Include detailed justification.