Sample Phs Form 5161-1: Sf 424a For New Access Points Page 4
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1
2
3
4Year 1
Budget Justification FY 2011-2013
Year 2
CHC
MHC
TOTAL: EQUIPMENT
$
$
$
ALTERATION AND RENOVATION (Summary of SF 424C)
$
Removal of interior wall
$
$
$
$
$
$
Installation of an HVAC system
Minor plumbing for oral operatory
$
$
$
TOTAL: ALTERATION AND RENOVATION
$
$
$
SUPPLIES
Office and Printing Supplies (for 3 sites)
$
$
$
Dental Supplies (2,000 visits @ $X.00 ea)
$
$
$
TOTAL: SUPPLIES
$
$
$
TRAVEL
Provider Training (2 FTEs @ $X.00 ea)
$
$
$
Outreach (50,000 miles @ $.XX per mile)
$
$
$
TOTAL: TRAVEL
$
$
$
CONTRACTUAL Describe with enough detail to justify costs for both
patient and non-patient contracts.
Outside Contract Pharmacies (3 pharmacies @ $XXX.00 per contract)
$
$
$
OB/GYN Contract with XX Practice ($XX.00 for deliveries for approx. 200
$
$
$
patients)
Housekeeping Services (Contract for services at 4 sites)
$
$
$
TOTAL: CONTRACTUAL
$
$
$
OTHER Describe with enough detail to justify each item in the “other”
category. Please note that Federal funding CANNOT support grant-
writing fees or other fundraising costs.
Audit Service with “X Firm”
$
$
$
Dues, Memberships
$
$
$
Rent ($X.00 per month, per site for 4 sites)
$
$
$
Technical Assistance
$
$
$
TOTAL: OTHER
$
$
$
TOTAL EXPENSES
$
$
$
Should be consistent with the totals presented in Sections A and B of the
SF-424A.
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