Form Sfy 01 - Home And Community Based Care - Alaska Commission On Aging Page 4
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10Alaska Commission on Aging
Home Community Based Care
Project:
Agency Name:
How expenses will be paid
ACoA funds by Allotment
Total
(300) Facility Expenses
Total ACoA
Local
Fees for
Other
Facility
Request
Match
Service
Sources
ACoA
MHTA
Cost
Rent, lease, depreciated value
Square Footage:
Rate per SF
Total Cost $
$
$
Utilities
$
$
Telephone
$
$
Minor repairs or maintenance
$
$
Other: (specify)
$
$
$
$
$
$
$
$
Totals
$
$
$
$
$
$
$
G:\ACOA\SFY01 NEW FORMS\ FY01 HCB Cost Proposals
CP 4
8/3/00
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