FY 2022 Annual Certification 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 information presented in the SF-424A and Form 3: Income Analysis)

REVENUE CERTIFICATION PERIOD
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
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
FICA @ X.XX%  
Medical @ X%  
Retirement @ X%  
Dental @ X%  
Unemployment & Workers Compensation @ X%  
Disability @ X%  
TOTAL FRINGE @ X%  

 

TRAVEL CERTIFICATION PERIOD
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
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
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
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
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
X% indirect cost rate (includes utilities and accounting services)  
TOTALS (Total of TOTAL DIRECT CHARGES and INDIRECT CHARGES)  

 

Additional Budget Justification

Date Last Reviewed:  August 2021