FY 2022 SAC 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 for each 12-month period (budget year) of the three-year period of performance (1-year period of performance for new applicants). Year 1 of the budget narrative should be classified into federal and non-federal resources, and a table of personnel to be paid with federal funds must be provided. For subsequent years, the budget narrative should highlight changes from Year 1 or clearly indicate there are no substantive changes during the period of performance. See Section 5.1 of HRSA’s SF-424 Two-Tier Application Guide (PDF - 729 KB).

Revenue

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

REVENUE Year 1: Federal Request Year 1:
Non-Federal Resources
Year 1
Total
Year 2
Total
Year 3
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. This should be consistent with the services listed in Form 1A: General Information.

PERSONNEL

(Include budget details for each staff position as seen in the Personnel Justification sample below)

Year 1: Federal Request Year 1:
Non-Federal Resources
Year 1
Total
Year 2
Total
Year 3
Total
ADMINISTRATION          
MEDICAL STAFF          
DENTAL STAFF          
BEHAVIORAL HEALTH STAFF:          
MENTAL HEALTH SERVICES          
SUBSTANCE USE DISORDER SERVICES          
VISION SERVICE          
ENABLING STAFF          
TOTAL PERSONNEL          

 

FRINGE BENEFITS Year 1: Federal Request Year 1:
Non-Federal Resources
Year 1
Total
Year 2
Total
Year 3
Total
FICA @ X.XX%          
Medical @ X%          
Retirement @ X%          
Dental @ X%          
Unemployment & Workers Compensation @ X%          
Disability @ X%          
TOTAL FRINGE @ X%          

 

TRAVEL Year 1: Federal Request Year 1:
Non-Federal Resources
Year 1
Total
Year 2
Total
Year 3
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.)

Year 1: Federal Request Year 1:
Non-Federal Resources
Year 1
Total
Year 2
Total
Year 3
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)

Year 1: Federal Request Year 1:
Non-Federal Resources
Year 1
Total
Year 2
Total
Year 3
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 project must be attached to Form 8.)

Year 1: Federal Request Year 1:
Non-Federal Resources
Year 1
Total
Year 2
Total
Year 3
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.)

Year 1: Federal Request Year 1:
Non-Federal Resources
Year 1
Total
Year 2
Total
Year 3
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.)

Year 1: Federal Request Year 1:
Non-Federal Resources
Year 1
Total
Year 2
Total
Year 3
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:  May 2021