Sample Phs Form 5161-1: Sf 424a For New Access Points
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4SAMPLE PHS FORM 5161-1: SF 424A FOR NEW ACCESS POINTS (First Page Only)
BUDGET INFORMATION – Non-Construction Programs
SECTION A – BUDGET SUMMARY
Grant Program
Catalog of
Estimated Unobligated Funds
New or Revised Budget
Function or
Fed Domestic
Activity
Assist No.
Federal
Non-Federal
Federal*
Non-Federal
Total
(a)
(b)
(c)
(d)
(e)
(f)
(g)
1. Migrant Health Centers - 330 (g)
93.224
$150,000
$3,452,767
$3,602,767.00
2. Community Health Centers- 330 (e)
93.224
$500,000
$7,599,423
$8,099,423.00
3.
4.
5. TOTALS
$650,000.00
$11,052,190.00
$11,702,190.00
SECTION B - BUDGET CATEGORIES
Grant Program Function or Activity
Total
6. Object Class Category
(5)
(1) Migrant
(2) Community
a.
Personnel
$6,040,153.00
$1,833,947
$4,206,206
b.
Fringe Benefits
$2,164,665.00
$676,241
$1,488,424
c.
Travel
$134,200.00
$41,924
$92,276
d.
Equipment
$675,557.00
$211,044
$464,513
e.
Supplies
$470,000.00
$146,828
$323,172
f.
Contractual
$941,200.00
$294,031
$647,169
g.
Construction
h.
Other
$1,276,415.00
$398,752
$877,663
i.
Total Direct Charges (sum of
$3,602,767
$8,099,423
$11,702,190.00
6a-6h)
j.
Indirect Charges
k.
TOTALS (sum of 6i and 6j)
$3,602,767
$8,099,423
$12,978,605.00
7. Program Income
$3,294,427
$7,251,113
$10,545,540
Standard Form 424A (7-97)
*Applicants are limited to the level of Federal funds identified in Program Guidance.
Prescribed by OMB Circular A-10
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