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.
Revenue
(Ensure totals are consistent with information provided in the Form 3: Income Analysis and Form 3A: Look-Alike Budget Information)
| 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
(Ensure object class totals are 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: $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 $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 $X each | |
| Staff Recruitment – newspaper and Internet posting | |
| Audit Services with HIJ Firm | |
| Property Insurance | |
| Repairs and Maintenance - not covered by warranty ($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) |
Personnel Justification Table - Sample
| Name | Position Title | % of FTE | Base Salary | Adjusted Annual Salary* | Federal Amount Requested |
|---|---|---|---|---|---|
| J. Smith | CEO | 50 | $255,000 | $225,700 | $112,980 |
| M. Green | Dentist | 100 | $230,000 | $225,700 | $225,700 |
| C. Moore | Physician | 50 | $200,000 | No adjustment needed | $100,000 |
| R. Doe | Nurse Practitioner | 100 | $120,000 | No adjustment needed | $120,000 |
| H. Black | Outreach Director | 50 | $70,000 | No adjustment needed | $35,000 |
| D. Jones | Data/AP Specialist | 25 | $50,000 | No adjustment needed | $12,500 |
| TOTAL | $606,180 |
*Effective January 2025, the salary rate limitation is $225,700. Use this column only when the salary is greater than $225,700.
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