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  5. Look-Alike Annual Certification Sample Budget Narrative

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.

Date Last Reviewed: