FY 2022 BPR Sample Budget Narrative

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

(Consistent with the information presented in the SF-424A and Form 3: Income Analysis)

REVENUE Federal Request Non-Federal Resources Total
SAC/SAC-AA 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 $199,300 $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 $199,300.

Date Last Reviewed:  June 2021