FY27 LAL-AC Sample Budget Narrative

This sample line-item budget narrative provides a broad outline of the information to include in a Health Center Program look-alike Annual Certification (AC) submission. A detailed budget narrative is required for all items within each category.

Jump to:

• Revenue
• Expenses

Revenue

(Ensure totals are consistent with information provided in Form 3: Income Analysis)

Object Class Category	Certification Period Amount
Health Center
State Funds
Local Funds
Other Support
Program Income (fees, third party reimbursements, and payments generated from the projected delivery of services)
TOTAL REVENUE

Expenses

Personnel

(Ensure object class totals are consistent with information presented in Form 3: Income Analysis)

Object Class Category	Certification Period Amount
Administration
Medical Services
Dental Staff
Mental Health Services
Substance Use Disorder Services
Vision Services
Patient Support Services
TOTAL PERSONNEL

Fringe Benefits

Object Class Category	Certification Period Amount
FICA @ X.XX%
Medical @ X%
Retirement @ X%
Dental @ X%
Unemployment & Workers Compensation @ X%
Disability @ X%
TOTAL FRINGE @ X%

Travel

Object Class Category	Certification Period Amount
Patient travel: $XXX,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 $10,000 or more and with a useful life of one year or more.

Object Class Category	Certification Period Amount
Ultrasound machine
3 dental chairs @ $X,XXX each
TOTAL EQUIPMENT

Supplies

Include items that cost less than $10,000 each and other supplies.

Object Class Category	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 a detailed explanation.

Object Class Category	Certification Period Amount
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 explanation.

Object Class Category	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)
Utilities
TOTAL OTHER
TOTAL DIRECT CHARGES (Sum of TOTAL Expenses)