Form 1B Funding Request Summary

OMB No.: 0915-0285 Expiration Date: 10/31/2013

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration FORM 1B: FUNDING REQUEST SUMMARY	FOR HRSA USE ONLY
	Application Tracking Number	Grant Number

Federal Funds Requested: Based on a 12-month Budget for each Budget Period
Type of Health Center	Program	Year 1	Year 2		Year 3	Year 4	Year 5
		Operational	Operational	Funding Population Percentage	Operational	Operational	Operational
Community Health Centers	CHC-330(e)				$0.00	$0.00	$0.00
Health Care for the Homeless	HCH-330(h)				$0.00	$0.00	$0.00
Migrant Health Centers	MHC-330(g)				$0.00	$0.00	$0.00
Public Housing Primary Care	PHPC-330(i)				$0.00	$0.00	$0.00
Total Operational Costs					$0.00	$0.00	$0.00
One-Time Funding					$0.00	$0.00	$0.00
Total Federal Funding Request					$0.00	$0.00	$0.00

One-time funds will be used for:

[_] Equipment only
[_] Minor alteration/renovation with equipment
[_] Minor alteration/renovation without equipment
[_] N/A

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 1 hour 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