The sample line-item budget narrative shown below is provided as a broad outline. A detailed budget narrative is required for all items within each category for which funds are requested.
Revenue
(Totals should be consistent with the information presented in the SF-424A and Form 3: Income Analysis)
| REVENUE | Federal Request | Non-Federal Resources | Total |
|---|---|---|---|
| BPR FUNDING REQUEST | |||
| 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 Section B of the SF-424A.)
|
PERSONNEL (Include budget details for each staff position as seen in the Personnel Justification sample below) |
Federal Request | Non-Federal Resources | Total |
|---|---|---|---|
| ADMINISTRATION | |||
| MEDICAL STAFF | |||
| DENTAL STAFF | |||
| BEHAVIORAL HEALTH STAFF: | |||
| MENTAL HEALTH SERVICES | |||
| SUBSTANCE USE DISORDER SERVICES | |||
| VISION SERVICE | |||
| ENABLING STAFF | |||
| TOTAL PERSONNEL |
| FRINGE BENEFITS | Federal Request | Non-Federal Resources | Total |
|---|---|---|---|
| FICA @ X.XX% | |||
| Medical @ X% | |||
| Retirement @ X% | |||
| Dental @ X% | |||
| Unemployment & Workers Compensation @ X% | |||
| Disability @ X% | |||
| TOTAL FRINGE @ X% |
| TRAVEL | Federal Request | Non-Federal Resources | Total |
|---|---|---|---|
| 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.) |
Federal Request | Non-Federal Resources | Total |
|---|---|---|---|
| Ultrasound machine | |||
| 3 dental chairs @ $X,XXX each | |||
| TOTAL EQUIPMENT |
|
SUPPLIES (Include equipment items that cost less than $5,000 each and other supplies) |
Federal Request | Non-Federal Resources | Total |
|---|---|---|---|
| 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 ($X.XX per visit x X,XXX visits) | |||
| TOTAL SUPPLIES |
|
CONTRACTUAL (Include detailed justification. Summaries of contracts must be included in Attachment 7. Contracts to perform substantive programmatic work within the proposed scope of the project must be attached to Form 8.) |
Federal Request | Non-Federal Resources | Total |
|---|---|---|---|
| Pharmacy Services ($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. Note: Federal funding CANNOT support grant-writing, construction, fundraising, or lobbying costs.) |
Federal Request | Non-Federal Resources | Total |
|---|---|---|---|
| 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 in Attachment 13: Other Relevant Documents.) |
Federal Request | Non-Federal Resources | Total |
|---|---|---|---|
| X% indirect cost rate (includes utilities and accounting services) | |||
| TOTALS(Total of TOTAL DIRECT CHARGES and INDIRECT CHARGES) |
Federal Personnel Justification Sample
| Name | Position Title | % of FTE | Base Salary | Adjusted Annual Salary* | Federal Amount Requested |
|---|---|---|---|---|---|
| C. Moore | CEO | 50 | $150,000 | No adjustment needed | $75,000 |
| J. Smith | Physician | 50 | $225,000 | $203,700 | $99,650 |
| R. Doe | Nurse Practitioner | 100 | $75,950 | No adjustment needed | $75,950 |
| M. Green | Dentist | 75 | $100,000 | No adjustment needed | $75,000 |
| D. Jones | Data/AP Specialist | 25 | $33,000 | No adjustment needed | $8,250 |
| H. Black | Outreach Director | 50 | $65,000 | No adjustment needed | $32,500 |
| S. White | Referral Specialist | 100 | $40,000 | No adjustment needed | $40,000 |
| TOTAL | $406,350 |
*Use this column only when the salary is over the limitation of $203,700.