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.
Date Last Reviewed: