Form 1 Look Alike Budget

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration Form 3A: FQHC Look-Alike Budget Information	FOR HRSA USE ONLY
	Application Tracking Number	LAL Number

	FQHC Look-Alike PROGRAM, FUNCTION OR ACTIVITY, Year 1
	Community Health Centers (CHC – 330(e))	Migrant Health Centers (MHC -330(g))	Health Care for Homeless (HCH – 330(h))	Public Housing Primary Care (PHPC -330(i))	Total
1. Expenses
a. Personnel
b. Fringe Benefits
c. Travel
d. Equipment
e. Supplies
f. Contractual
g. Construction
h. Other
i. Total Direct Charges (sum of a through h)
j. Indirect Charges
k. Total Expenses (sum of i and j)
2. Revenue
a. Applicant
b. Federal
c. State
d. Local
e. Other
f. Program Income
g. Total Revenue (sum of a through f)

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.