Form 0285 funding 0285 funding 0285 funding summary

OMB No.: 0915-0285. Expiration Date: xx/xx/xxxx
FOR HRSA USE ONLY

DEPARTMENT OF HEALTH AND HUMAN
SERVICES
Health Resources and Services
Administration

Application Tracking Number

Grant Number

BPHC FUNDING REQUEST SUMMARY
Note: These values are populated from the standard application budget forms. Any updates to the standard application budget form
requires an update in program-specific project budget estimation.

FEDERAL FUNDS REQUESTED: BASED ON A 12-MONTH BUDGET FOR EACH BUDGET PERIOD
Type of Health
Center

Year 1
Program

Community
Health Center

CHC-330
(e)

Migrant Health
Center

MHC-330
(g)

Health Care for
the Homeless

HCH-330
(h)

Public Housing
Primary Care

PHPC-330
(i)

Operational

OneTime

Year 2

Year 3

Year 4

Year 5

Operational

Operational

Operational

Operational

Total Federal Funding Request
Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915-0285. Public
reporting burden for this collection of information is estimated to average .5 hours per response, including the time for reviewing
instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding
this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA
Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.