Form 1B Funding Request Summary

The Health Center Program Application Forms

02. Form 1B - BPHC Funding Request Summary

Funding Request Summary

OMB: 0915-0285

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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

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AuthorSameer Vajre
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