Basic Annual Budget

Monitoring and Reporting System for the State Public Health Actions Cooperative Agreements

Att 4b. Budget (Basic and Enhanced).xlsx

Basic Awardees Annual Budget

OMB: 0920-1059

Document [xlsx]
Download: xlsx | pdf

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424A-SectionB_PPHF
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In-Kind Funding (Optional)


Sheet 1: Home Page








1305 Year 2 Budget (PPHF)




Form Approved
OMB No. 0920-XXXX
Exp. Date XX/XX/XXXX







State Public Health Actions to Prevent and Control Diabetes, Heart Disease, Obesity and Associated Risk Factors and Promote School Health












<Enter State Name>








































Workbook Contents










































Instructions



























































Public reporting of this collection of information varies from 1 to 9 hours per response, including the time for reviewing instructions,


















searching existing data sources, gathering and maintaining the data needed and completing and reviewing the collection of information.


















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. Send comments regarding this burden estimate or any other aspect of this collection of


















information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74,


















Atlanta, Georgia 30333; ATTN:PRA (0920-XXXX).


















Sheet 2: Personnel Salary and Fringe






















Personnel Salary and Fringe































Personnel Cost










Name Position Title Annual Salary and Wages % Paid by This Grant Months Salary and Wages Fringe (%) Fringe ($)
if not %
Fringe Total Planned















$-

$- $-










Allocation of Cost by Domain and Funding Category Justification










Funding Category
Domain
HDSP Diabetes NPAO SH Domain Total











Basic Activities 0.0% 0.0% 0.0% ($0)










Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0)




















































Personnel Cost










Name Position Title Annual Salary and Wages % Paid by This Grant Months Salary and Wages Fringe (%) Fringe ($)
if not %
Fringe Total Planned















$-

$- $-










Allocation of Cost by Domain and Funding Category Justification










Funding Category
Domain
HDSP Diabetes NPAO SH Domain Total











Basic Activities 0.0% 0.0% 0.0% ($0)










Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0)




















































Personnel Cost










Name Position Title Annual Salary and Wages % Paid by This Grant Months Salary and Wages Fringe (%) Fringe ($)
if not %
Fringe Total Planned















$-

$- $-










Allocation of Cost by Domain and Funding Category Justification










Funding Category
Domain
HDSP Diabetes NPAO SH Domain Total











Basic Activities 0.0% 0.0% 0.0% ($0)










Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0)




















































Personnel Cost










Name Position Title Annual Salary and Wages % Paid by This Grant Months Salary and Wages Fringe (%) Fringe ($)
if not %
Fringe Total Planned















$-

$- $-










Allocation of Cost by Domain and Funding Category Justification










Funding Category
Domain
HDSP Diabetes NPAO SH Domain Total











Basic Activities 0.0% 0.0% 0.0% ($0)










Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0)




















































Personnel Cost










Name Position Title Annual Salary and Wages % Paid by This Grant Months Salary and Wages Fringe (%) Fringe ($)
if not %
Fringe Total Planned















$-

$- $-










Allocation of Cost by Domain and Funding Category Justification










Funding Category
Domain
HDSP Diabetes NPAO SH Domain Total











Basic Activities 0.0% 0.0% 0.0% ($0)










Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0)




















































Personnel Cost










Name Position Title Annual Salary and Wages % Paid by This Grant Months Salary and Wages Fringe (%) Fringe ($)
if not %
Fringe Total Planned















$-

$- $-










Allocation of Cost by Domain and Funding Category Justification










Funding Category
Domain
HDSP Diabetes NPAO SH Domain Total











Basic Activities 0.0% 0.0% 0.0% ($0)










Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0)




















































Personnel Cost










Name Position Title Annual Salary and Wages % Paid by This Grant Months Salary and Wages Fringe (%) Fringe ($)
if not %
Fringe Total Planned















$-

$- $-










Allocation of Cost by Domain and Funding Category Justification










Funding Category
Domain
HDSP Diabetes NPAO SH Domain Total











Basic Activities 0.0% 0.0% 0.0% ($0)










Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0)




















































Personnel Cost










Name Position Title Annual Salary and Wages % Paid by This Grant Months Salary and Wages Fringe (%) Fringe ($)
if not %
Fringe Total Planned















$-

$- $-










Allocation of Cost by Domain and Funding Category Justification










Funding Category
Domain
HDSP Diabetes NPAO SH Domain Total











Basic Activities 0.0% 0.0% 0.0% ($0)










Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0)




















































Personnel Cost










Name Position Title Annual Salary and Wages % Paid by This Grant Months Salary and Wages Fringe (%) Fringe ($)
if not %
Fringe Total Planned















$-

$- $-










Allocation of Cost by Domain and Funding Category Justification










Funding Category
Domain
HDSP Diabetes NPAO SH Domain Total











Basic Activities 0.0% 0.0% 0.0% ($0)










Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0)




















































Personnel Cost










Name Position Title Annual Salary and Wages % Paid by This Grant Months Salary and Wages Fringe (%) Fringe ($)
if not %
Fringe Total Planned















$-

$- $-










Allocation of Cost by Domain and Funding Category Justification










Funding Category
Domain
HDSP Diabetes NPAO SH Domain Total











Basic Activities 0.0% 0.0% 0.0% ($0)










Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0)




















































Personnel Cost










Name Position Title Annual Salary and Wages % Paid by This Grant Months Salary and Wages Fringe (%) Fringe ($)
if not %
Fringe Total Planned















$-

$- $-










Allocation of Cost by Domain and Funding Category Justification










Funding Category
Domain
HDSP Diabetes NPAO SH Domain Total











Basic Activities 0.0% 0.0% 0.0% ($0)










Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0)




















































Personnel Cost










Name Position Title Annual Salary and Wages % Paid by This Grant Months Salary and Wages Fringe (%) Fringe ($)
if not %
Fringe Total Planned















$-

$- $-










Allocation of Cost by Domain and Funding Category Justification










Funding Category
Domain
HDSP Diabetes NPAO SH Domain Total











Basic Activities 0.0% 0.0% 0.0% ($0)










Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0)




















































Personnel Cost










Name Position Title Annual Salary and Wages % Paid by This Grant Months Salary and Wages Fringe (%) Fringe ($)
if not %
Fringe Total Planned















$-

$- $-










Allocation of Cost by Domain and Funding Category Justification










Funding Category
Domain
HDSP Diabetes NPAO SH Domain Total











Basic Activities 0.0% 0.0% 0.0% ($0)










Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0)




















































Personnel Cost










Name Position Title Annual Salary and Wages % Paid by This Grant Months Salary and Wages Fringe (%) Fringe ($)
if not %
Fringe Total Planned















$-

$- $-










Allocation of Cost by Domain and Funding Category Justification










Funding Category
Domain
HDSP Diabetes NPAO SH Domain Total











Basic Activities 0.0% 0.0% 0.0% ($0)










Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0)




















































Personnel Cost










Name Position Title Annual Salary and Wages % Paid by This Grant Months Salary and Wages Fringe (%) Fringe ($)
if not %
Fringe Total Planned















$-

$- $-










Allocation of Cost by Domain and Funding Category Justification










Funding Category
Domain
HDSP Diabetes NPAO SH Domain Total











Basic Activities 0.0% 0.0% 0.0% ($0)










Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0)




















































Personnel Cost










Name Position Title Annual Salary and Wages % Paid by This Grant Months Salary and Wages Fringe (%) Fringe ($)
if not %
Fringe Total Planned















$-

$- $-










Allocation of Cost by Domain and Funding Category Justification










Funding Category
Domain
HDSP Diabetes NPAO SH Domain Total











Basic Activities 0.0% 0.0% 0.0% ($0)










Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0)




















































Personnel Cost










Name Position Title Annual Salary and Wages % Paid by This Grant Months Salary and Wages Fringe (%) Fringe ($)
if not %
Fringe Total Planned















$-

$- $-










Allocation of Cost by Domain and Funding Category Justification










Funding Category
Domain
HDSP Diabetes NPAO SH Domain Total











Basic Activities 0.0% 0.0% 0.0% ($0)










Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0)




















































Personnel Cost










Name Position Title Annual Salary and Wages % Paid by This Grant Months Salary and Wages Fringe (%) Fringe ($)
if not %
Fringe Total Planned















$-

$- $-










Allocation of Cost by Domain and Funding Category Justification










Funding Category
Domain
HDSP Diabetes NPAO SH Domain Total











Basic Activities 0.0% 0.0% 0.0% ($0)










Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0)




















































Personnel Cost










Name Position Title Annual Salary and Wages % Paid by This Grant Months Salary and Wages Fringe (%) Fringe ($)
if not %
Fringe Total Planned















$-

$- $-










Allocation of Cost by Domain and Funding Category Justification










Funding Category
Domain
HDSP Diabetes NPAO SH Domain Total











Basic Activities 0.0% 0.0% 0.0% ($0)










Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0)




















































Personnel Cost










Name Position Title Annual Salary and Wages % Paid by This Grant Months Salary and Wages Fringe (%) Fringe ($)
if not %
Fringe Total Planned















$-

$- $-










Allocation of Cost by Domain and Funding Category Justification










Funding Category
Domain
HDSP Diabetes NPAO SH Domain Total











Basic Activities 0.0% 0.0% 0.0% ($0)










Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0)




















































Personnel Cost










Name Position Title Annual Salary and Wages % Paid by This Grant Months Salary and Wages Fringe (%) Fringe ($)
if not %
Fringe Total Planned















$-

$- $-










Allocation of Cost by Domain and Funding Category Justification










Funding Category
Domain
HDSP Diabetes NPAO SH Domain Total











Basic Activities 0.0% 0.0% 0.0% ($0)










Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0)




















































Personnel Cost










Name Position Title Annual Salary and Wages % Paid by This Grant Months Salary and Wages Fringe (%) Fringe ($)
if not %
Fringe Total Planned















$-

$- $-










Allocation of Cost by Domain and Funding Category Justification










Funding Category
Domain
HDSP Diabetes NPAO SH Domain Total











Basic Activities 0.0% 0.0% 0.0% ($0)










Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0)




















































Personnel Cost










Name Position Title Annual Salary and Wages % Paid by This Grant Months Salary and Wages Fringe (%) Fringe ($)
if not %
Fringe Total Planned















$-

$- $-










Allocation of Cost by Domain and Funding Category Justification










Funding Category
Domain
HDSP Diabetes NPAO SH Domain Total











Basic Activities 0.0% 0.0% 0.0% ($0)










Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0)




















































Personnel Cost










Name Position Title Annual Salary and Wages % Paid by This Grant Months Salary and Wages Fringe (%) Fringe ($)
if not %
Fringe Total Planned















$-

$- $-










Allocation of Cost by Domain and Funding Category Justification










Funding Category
Domain
HDSP Diabetes NPAO SH Domain Total











Basic Activities 0.0% 0.0% 0.0% ($0)










Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0)




















































Personnel Cost










Name Position Title Annual Salary and Wages % Paid by This Grant Months Salary and Wages Fringe (%) Fringe ($)
if not %
Fringe Total Planned















$-

$- $-










Allocation of Cost by Domain and Funding Category Justification










Funding Category
Domain
HDSP Diabetes NPAO SH Domain Total











Basic Activities 0.0% 0.0% 0.0% ($0)










Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0)




















































Personnel Cost










Name Position Title Annual Salary and Wages % Paid by This Grant Months Salary and Wages Fringe (%) Fringe ($)
if not %
Fringe Total Planned















$-

$- $-










Allocation of Cost by Domain and Funding Category Justification










Funding Category
Domain
HDSP Diabetes NPAO SH Domain Total











Basic Activities 0.0% 0.0% 0.0% ($0)










Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0)




















































Personnel Cost










Name Position Title Annual Salary and Wages % Paid by This Grant Months Salary and Wages Fringe (%) Fringe ($)
if not %
Fringe Total Planned















$-

$- $-










Allocation of Cost by Domain and Funding Category Justification










Funding Category
Domain
HDSP Diabetes NPAO SH Domain Total











Basic Activities 0.0% 0.0% 0.0% ($0)










Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0)




















































Personnel Cost










Name Position Title Annual Salary and Wages % Paid by This Grant Months Salary and Wages Fringe (%) Fringe ($)
if not %
Fringe Total Planned















$-

$- $-










Allocation of Cost by Domain and Funding Category Justification










Funding Category
Domain
HDSP Diabetes NPAO SH Domain Total











Basic Activities 0.0% 0.0% 0.0% ($0)










Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0)




















































Personnel Cost










Name Position Title Annual Salary and Wages % Paid by This Grant Months Salary and Wages Fringe (%) Fringe ($)
if not %
Fringe Total Planned















$-

$- $-










Allocation of Cost by Domain and Funding Category Justification










Funding Category
Domain
HDSP Diabetes NPAO SH Domain Total











Basic Activities 0.0% 0.0% 0.0% ($0)










Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0)




















































Personnel Cost










Name Position Title Annual Salary and Wages % Paid by This Grant Months Salary and Wages Fringe (%) Fringe ($)
if not %
Fringe Total Planned















$-

$- $-










Allocation of Cost by Domain and Funding Category Justification










Funding Category
Domain
HDSP Diabetes NPAO SH Domain Total











Basic Activities 0.0% 0.0% 0.0% ($0)










Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0)




















































Personnel Cost










Name Position Title Annual Salary and Wages % Paid by This Grant Months Salary and Wages Fringe (%) Fringe ($)
if not %
Fringe Total Planned















$-

$- $-










Allocation of Cost by Domain and Funding Category Justification










Funding Category
Domain
HDSP Diabetes NPAO SH Domain Total











Basic Activities 0.0% 0.0% 0.0% ($0)










Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0)




















































Personnel Cost










Name Position Title Annual Salary and Wages % Paid by This Grant Months Salary and Wages Fringe (%) Fringe ($)
if not %
Fringe Total Planned















$-

$- $-










Allocation of Cost by Domain and Funding Category Justification










Funding Category
Domain
HDSP Diabetes NPAO SH Domain Total











Basic Activities 0.0% 0.0% 0.0% ($0)










Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0)




















































Personnel Cost










Name Position Title Annual Salary and Wages % Paid by This Grant Months Salary and Wages Fringe (%) Fringe ($)
if not %
Fringe Total Planned















$-

$- $-










Allocation of Cost by Domain and Funding Category Justification










Funding Category
Domain
HDSP Diabetes NPAO SH Domain Total











Basic Activities 0.0% 0.0% 0.0% ($0)










Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0)




















































Personnel Cost










Name Position Title Annual Salary and Wages % Paid by This Grant Months Salary and Wages Fringe (%) Fringe ($)
if not %
Fringe Total Planned















$-

$- $-










Allocation of Cost by Domain and Funding Category Justification










Funding Category
Domain
HDSP Diabetes NPAO SH Domain Total











Basic Activities 0.0% 0.0% 0.0% ($0)










Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0)




















































Personnel Cost










Name Position Title Annual Salary and Wages % Paid by This Grant Months Salary and Wages Fringe (%) Fringe ($)
if not %
Fringe Total Planned















$-

$- $-










Allocation of Cost by Domain and Funding Category Justification










Funding Category
Domain
HDSP Diabetes NPAO SH Domain Total











Basic Activities 0.0% 0.0% 0.0% ($0)










Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0)




















































Personnel Cost










Name Position Title Annual Salary and Wages % Paid by This Grant Months Salary and Wages Fringe (%) Fringe ($)
if not %
Fringe Total Planned















$-

$- $-










Allocation of Cost by Domain and Funding Category Justification










Funding Category
Domain
HDSP Diabetes NPAO SH Domain Total











Basic Activities 0.0% 0.0% 0.0% ($0)










Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0)




















































Personnel Cost










Name Position Title Annual Salary and Wages % Paid by This Grant Months Salary and Wages Fringe (%) Fringe ($)
if not %
Fringe Total Planned















$-

$- $-










Allocation of Cost by Domain and Funding Category Justification










Funding Category
Domain
HDSP Diabetes NPAO SH Domain Total











Basic Activities 0.0% 0.0% 0.0% ($0)










Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0)




















































Personnel Cost










Name Position Title Annual Salary and Wages % Paid by This Grant Months Salary and Wages Fringe (%) Fringe ($)
if not %
Fringe Total Planned















$-

$- $-










Allocation of Cost by Domain and Funding Category Justification










Funding Category
Domain
HDSP Diabetes NPAO SH Domain Total











Basic Activities 0.0% 0.0% 0.0% ($0)










Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0)




















































Personnel Cost










Name Position Title Annual Salary and Wages % Paid by This Grant Months Salary and Wages Fringe (%) Fringe ($)
if not %
Fringe Total Planned















$-

$- $-










Allocation of Cost by Domain and Funding Category Justification










Funding Category
Domain
HDSP Diabetes NPAO SH Domain Total











Basic Activities 0.0% 0.0% 0.0% ($0)










Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0)




















































Personnel Cost










Name Position Title Annual Salary and Wages % Paid by This Grant Months Salary and Wages Fringe (%) Fringe ($)
if not %
Fringe Total Planned















$-

$- $-










Allocation of Cost by Domain and Funding Category Justification










Funding Category
Domain
HDSP Diabetes NPAO SH Domain Total











Basic Activities 0.0% 0.0% 0.0% ($0)










Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0)










Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0)











Sheet 3: Contracts


















Contracts























Basic Information Itemized Costs Justification






Name of Contractor
Salary and Wages $-







Method of Selection
Fringe Benefits $-







Justification for Sole Source Selection (if applicable)
Consultant Costs $-







Period of Performance
Equipment $-







Scope of Work
Supplies $-







Travel $-







Method of Accountability
Deliverable Cost <enter description> $-







Other <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Subcontract Costs $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL DIRECT COSTS $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Indirect Rate








Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL INDIRECT COSTS $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONTRACT $-









































Basic Information Itemized Costs Justification






Name of Contractor
Salary and Wages $-







Method of Selection
Fringe Benefits $-







Justification for Sole Source Selection (if applicable)
Consultant Costs $-







Period of Performance
Equipment $-







Scope of Work
Supplies $-







Travel $-







Method of Accountability
Deliverable Cost <enter description> $-







Other <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Subcontract Costs $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL DIRECT COSTS $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Indirect Rate








Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL INDIRECT COSTS $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONTRACT $-









































Basic Information Itemized Costs Justification






Name of Contractor
Salary and Wages $-







Method of Selection
Fringe Benefits $-







Justification for Sole Source Selection (if applicable)
Consultant Costs $-







Period of Performance
Equipment $-







Scope of Work
Supplies $-







Travel $-







Method of Accountability
Deliverable Cost <enter description> $-







Other <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Subcontract Costs $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL DIRECT COSTS $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Indirect Rate








Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL INDIRECT COSTS $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONTRACT $-









































Basic Information Itemized Costs Justification






Name of Contractor
Salary and Wages $-







Method of Selection
Fringe Benefits $-







Justification for Sole Source Selection (if applicable)
Consultant Costs $-







Period of Performance
Equipment $-







Scope of Work
Supplies $-







Travel $-







Method of Accountability
Deliverable Cost <enter description> $-







Other <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Subcontract Costs $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL DIRECT COSTS $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Indirect Rate








Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL INDIRECT COSTS $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONTRACT $-









































Basic Information Itemized Costs Justification






Name of Contractor
Salary and Wages $-







Method of Selection
Fringe Benefits $-







Justification for Sole Source Selection (if applicable)
Consultant Costs $-







Period of Performance
Equipment $-







Scope of Work
Supplies $-







Travel $-







Method of Accountability
Deliverable Cost <enter description> $-







Other <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Subcontract Costs $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL DIRECT COSTS $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Indirect Rate








Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL INDIRECT COSTS $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONTRACT $-









































Basic Information Itemized Costs Justification






Name of Contractor
Salary and Wages $-







Method of Selection
Fringe Benefits $-







Justification for Sole Source Selection (if applicable)
Consultant Costs $-







Period of Performance
Equipment $-







Scope of Work
Supplies $-







Travel $-







Method of Accountability
Deliverable Cost <enter description> $-







Other <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Subcontract Costs $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL DIRECT COSTS $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Indirect Rate








Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL INDIRECT COSTS $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONTRACT $-









































Basic Information Itemized Costs Justification






Name of Contractor
Salary and Wages $-







Method of Selection
Fringe Benefits $-







Justification for Sole Source Selection (if applicable)
Consultant Costs $-







Period of Performance
Equipment $-







Scope of Work
Supplies $-







Travel $-







Method of Accountability
Deliverable Cost <enter description> $-







Other <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Subcontract Costs $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL DIRECT COSTS $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Indirect Rate








Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL INDIRECT COSTS $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONTRACT $-









































Basic Information Itemized Costs Justification






Name of Contractor
Salary and Wages $-







Method of Selection
Fringe Benefits $-







Justification for Sole Source Selection (if applicable)
Consultant Costs $-







Period of Performance
Equipment $-







Scope of Work
Supplies $-







Travel $-







Method of Accountability
Deliverable Cost <enter description> $-







Other <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Subcontract Costs $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL DIRECT COSTS $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Indirect Rate








Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL INDIRECT COSTS $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONTRACT $-









































Basic Information Itemized Costs Justification






Name of Contractor
Salary and Wages $-







Method of Selection
Fringe Benefits $-







Justification for Sole Source Selection (if applicable)
Consultant Costs $-







Period of Performance
Equipment $-







Scope of Work
Supplies $-







Travel $-







Method of Accountability
Deliverable Cost <enter description> $-







Other <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Subcontract Costs $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL DIRECT COSTS $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Indirect Rate








Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL INDIRECT COSTS $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONTRACT $-









































Basic Information Itemized Costs Justification






Name of Contractor
Salary and Wages $-







Method of Selection
Fringe Benefits $-







Justification for Sole Source Selection (if applicable)
Consultant Costs $-







Period of Performance
Equipment $-







Scope of Work
Supplies $-







Travel $-







Method of Accountability
Deliverable Cost <enter description> $-







Other <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Subcontract Costs $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL DIRECT COSTS $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Indirect Rate








Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL INDIRECT COSTS $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONTRACT $-









































Basic Information Itemized Costs Justification






Name of Contractor
Salary and Wages $-







Method of Selection
Fringe Benefits $-







Justification for Sole Source Selection (if applicable)
Consultant Costs $-







Period of Performance
Equipment $-







Scope of Work
Supplies $-







Travel $-







Method of Accountability
Deliverable Cost <enter description> $-







Other <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Subcontract Costs $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL DIRECT COSTS $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Indirect Rate








Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL INDIRECT COSTS $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONTRACT $-









































Basic Information Itemized Costs Justification






Name of Contractor
Salary and Wages $-







Method of Selection
Fringe Benefits $-







Justification for Sole Source Selection (if applicable)
Consultant Costs $-







Period of Performance
Equipment $-







Scope of Work
Supplies $-







Travel $-







Method of Accountability
Deliverable Cost <enter description> $-







Other <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Subcontract Costs $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL DIRECT COSTS $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Indirect Rate








Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL INDIRECT COSTS $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONTRACT $-









































Basic Information Itemized Costs Justification






Name of Contractor
Salary and Wages $-







Method of Selection
Fringe Benefits $-







Justification for Sole Source Selection (if applicable)
Consultant Costs $-







Period of Performance
Equipment $-







Scope of Work
Supplies $-







Travel $-







Method of Accountability
Deliverable Cost <enter description> $-







Other <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Subcontract Costs $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL DIRECT COSTS $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Indirect Rate








Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL INDIRECT COSTS $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONTRACT $-









































Basic Information Itemized Costs Justification






Name of Contractor
Salary and Wages $-







Method of Selection
Fringe Benefits $-







Justification for Sole Source Selection (if applicable)
Consultant Costs $-







Period of Performance
Equipment $-







Scope of Work
Supplies $-







Travel $-







Method of Accountability
Deliverable Cost <enter description> $-







Other <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Subcontract Costs $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL DIRECT COSTS $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Indirect Rate








Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL INDIRECT COSTS $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONTRACT $-









































Basic Information Itemized Costs Justification






Name of Contractor
Salary and Wages $-







Method of Selection
Fringe Benefits $-







Justification for Sole Source Selection (if applicable)
Consultant Costs $-







Period of Performance
Equipment $-







Scope of Work
Supplies $-







Travel $-







Method of Accountability
Deliverable Cost <enter description> $-







Other <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Subcontract Costs $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL DIRECT COSTS $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Indirect Rate








Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL INDIRECT COSTS $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONTRACT $-









































Basic Information Itemized Costs Justification






Name of Contractor
Salary and Wages $-







Method of Selection
Fringe Benefits $-







Justification for Sole Source Selection (if applicable)
Consultant Costs $-







Period of Performance
Equipment $-







Scope of Work
Supplies $-







Travel $-







Method of Accountability
Deliverable Cost <enter description> $-







Other <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Subcontract Costs $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL DIRECT COSTS $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Indirect Rate








Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL INDIRECT COSTS $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONTRACT $-









































Basic Information Itemized Costs Justification






Name of Contractor
Salary and Wages $-







Method of Selection
Fringe Benefits $-







Justification for Sole Source Selection (if applicable)
Consultant Costs $-







Period of Performance
Equipment $-







Scope of Work
Supplies $-







Travel $-







Method of Accountability
Deliverable Cost <enter description> $-







Other <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Subcontract Costs $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL DIRECT COSTS $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Indirect Rate








Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL INDIRECT COSTS $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONTRACT $-









































Basic Information Itemized Costs Justification






Name of Contractor
Salary and Wages $-







Method of Selection
Fringe Benefits $-







Justification for Sole Source Selection (if applicable)
Consultant Costs $-







Period of Performance
Equipment $-







Scope of Work
Supplies $-







Travel $-







Method of Accountability
Deliverable Cost <enter description> $-







Other <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Subcontract Costs $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL DIRECT COSTS $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Indirect Rate








Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL INDIRECT COSTS $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONTRACT $-









































Basic Information Itemized Costs Justification






Name of Contractor
Salary and Wages $-







Method of Selection
Fringe Benefits $-







Justification for Sole Source Selection (if applicable)
Consultant Costs $-







Period of Performance
Equipment $-







Scope of Work
Supplies $-







Travel $-







Method of Accountability
Deliverable Cost <enter description> $-







Other <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Subcontract Costs $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL DIRECT COSTS $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Indirect Rate








Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL INDIRECT COSTS $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONTRACT $-









































Basic Information Itemized Costs Justification






Name of Contractor
Salary and Wages $-







Method of Selection
Fringe Benefits $-







Justification for Sole Source Selection (if applicable)
Consultant Costs $-







Period of Performance
Equipment $-







Scope of Work
Supplies $-







Travel $-







Method of Accountability
Deliverable Cost <enter description> $-







Other <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Subcontract Costs $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL DIRECT COSTS $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Indirect Rate








Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL INDIRECT COSTS $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONTRACT $-









































Basic Information Itemized Costs Justification






Name of Contractor
Salary and Wages $-







Method of Selection
Fringe Benefits $-







Justification for Sole Source Selection (if applicable)
Consultant Costs $-







Period of Performance
Equipment $-







Scope of Work
Supplies $-







Travel $-







Method of Accountability
Deliverable Cost <enter description> $-







Other <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Subcontract Costs $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL DIRECT COSTS $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Indirect Rate








Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL INDIRECT COSTS $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONTRACT $-









































Basic Information Itemized Costs Justification






Name of Contractor
Salary and Wages $-







Method of Selection
Fringe Benefits $-







Justification for Sole Source Selection (if applicable)
Consultant Costs $-







Period of Performance
Equipment $-







Scope of Work
Supplies $-







Travel $-







Method of Accountability
Deliverable Cost <enter description> $-







Other <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Subcontract Costs $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL DIRECT COSTS $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Indirect Rate








Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL INDIRECT COSTS $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONTRACT $-









































Basic Information Itemized Costs Justification






Name of Contractor
Salary and Wages $-







Method of Selection
Fringe Benefits $-







Justification for Sole Source Selection (if applicable)
Consultant Costs $-







Period of Performance
Equipment $-







Scope of Work
Supplies $-







Travel $-







Method of Accountability
Deliverable Cost <enter description> $-







Other <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Subcontract Costs $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL DIRECT COSTS $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Indirect Rate








Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL INDIRECT COSTS $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONTRACT $-









































Basic Information Itemized Costs Justification






Name of Contractor
Salary and Wages $-







Method of Selection
Fringe Benefits $-







Justification for Sole Source Selection (if applicable)
Consultant Costs $-







Period of Performance
Equipment $-







Scope of Work
Supplies $-







Travel $-







Method of Accountability
Deliverable Cost <enter description> $-







Other <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Subcontract Costs $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL DIRECT COSTS $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Indirect Rate








Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL INDIRECT COSTS $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONTRACT $-









































Basic Information Itemized Costs Justification






Name of Contractor
Salary and Wages $-







Method of Selection
Fringe Benefits $-







Justification for Sole Source Selection (if applicable)
Consultant Costs $-







Period of Performance
Equipment $-







Scope of Work
Supplies $-







Travel $-







Method of Accountability
Deliverable Cost <enter description> $-







Other <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Subcontract Costs $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL DIRECT COSTS $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Indirect Rate








Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL INDIRECT COSTS $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONTRACT $-









































Basic Information Itemized Costs Justification






Name of Contractor
Salary and Wages $-







Method of Selection
Fringe Benefits $-







Justification for Sole Source Selection (if applicable)
Consultant Costs $-







Period of Performance
Equipment $-







Scope of Work
Supplies $-







Travel $-







Method of Accountability
Deliverable Cost <enter description> $-







Other <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Subcontract Costs $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL DIRECT COSTS $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Indirect Rate








Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL INDIRECT COSTS $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONTRACT $-









































Basic Information Itemized Costs Justification






Name of Contractor
Salary and Wages $-







Method of Selection
Fringe Benefits $-







Justification for Sole Source Selection (if applicable)
Consultant Costs $-







Period of Performance
Equipment $-







Scope of Work
Supplies $-







Travel $-







Method of Accountability
Deliverable Cost <enter description> $-







Other <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Subcontract Costs $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL DIRECT COSTS $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Indirect Rate








Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL INDIRECT COSTS $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONTRACT $-









































Basic Information Itemized Costs Justification






Name of Contractor
Salary and Wages $-







Method of Selection
Fringe Benefits $-







Justification for Sole Source Selection (if applicable)
Consultant Costs $-







Period of Performance
Equipment $-







Scope of Work
Supplies $-







Travel $-







Method of Accountability
Deliverable Cost <enter description> $-







Other <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Subcontract Costs $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL DIRECT COSTS $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Indirect Rate








Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL INDIRECT COSTS $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONTRACT $-









































Basic Information Itemized Costs Justification






Name of Contractor
Salary and Wages $-







Method of Selection
Fringe Benefits $-







Justification for Sole Source Selection (if applicable)
Consultant Costs $-







Period of Performance
Equipment $-







Scope of Work
Supplies $-







Travel $-







Method of Accountability
Deliverable Cost <enter description> $-







Other <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Subcontract Costs $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL DIRECT COSTS $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Indirect Rate








Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL INDIRECT COSTS $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONTRACT $-









































Basic Information Itemized Costs Justification






Name of Contractor
Salary and Wages $-







Method of Selection
Fringe Benefits $-







Justification for Sole Source Selection (if applicable)
Consultant Costs $-







Period of Performance
Equipment $-







Scope of Work
Supplies $-







Travel $-







Method of Accountability
Deliverable Cost <enter description> $-







Other <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Subcontract Costs $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL DIRECT COSTS $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Indirect Rate








Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL INDIRECT COSTS $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONTRACT $-









































Basic Information Itemized Costs Justification






Name of Contractor
Salary and Wages $-







Method of Selection
Fringe Benefits $-







Justification for Sole Source Selection (if applicable)
Consultant Costs $-







Period of Performance
Equipment $-







Scope of Work
Supplies $-







Travel $-







Method of Accountability
Deliverable Cost <enter description> $-







Other <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Subcontract Costs $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL DIRECT COSTS $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Indirect Rate








Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL INDIRECT COSTS $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONTRACT $-









































Basic Information Itemized Costs Justification






Name of Contractor
Salary and Wages $-







Method of Selection
Fringe Benefits $-







Justification for Sole Source Selection (if applicable)
Consultant Costs $-







Period of Performance
Equipment $-







Scope of Work
Supplies $-







Travel $-







Method of Accountability
Deliverable Cost <enter description> $-







Other <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Subcontract Costs $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL DIRECT COSTS $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Indirect Rate








Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL INDIRECT COSTS $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONTRACT $-









































Basic Information Itemized Costs Justification






Name of Contractor
Salary and Wages $-







Method of Selection
Fringe Benefits $-







Justification for Sole Source Selection (if applicable)
Consultant Costs $-







Period of Performance
Equipment $-







Scope of Work
Supplies $-







Travel $-







Method of Accountability
Deliverable Cost <enter description> $-







Other <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Subcontract Costs $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL DIRECT COSTS $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Indirect Rate








Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL INDIRECT COSTS $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONTRACT $-









































Basic Information Itemized Costs Justification






Name of Contractor
Salary and Wages $-







Method of Selection
Fringe Benefits $-







Justification for Sole Source Selection (if applicable)
Consultant Costs $-







Period of Performance
Equipment $-







Scope of Work
Supplies $-







Travel $-







Method of Accountability
Deliverable Cost <enter description> $-







Other <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Subcontract Costs $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL DIRECT COSTS $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Indirect Rate








Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL INDIRECT COSTS $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONTRACT $-









































Basic Information Itemized Costs Justification






Name of Contractor
Salary and Wages $-







Method of Selection
Fringe Benefits $-







Justification for Sole Source Selection (if applicable)
Consultant Costs $-







Period of Performance
Equipment $-







Scope of Work
Supplies $-







Travel $-







Method of Accountability
Deliverable Cost <enter description> $-







Other <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Subcontract Costs $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL DIRECT COSTS $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Indirect Rate








Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL INDIRECT COSTS $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONTRACT $-









































Basic Information Itemized Costs Justification






Name of Contractor
Salary and Wages $-







Method of Selection
Fringe Benefits $-







Justification for Sole Source Selection (if applicable)
Consultant Costs $-







Period of Performance
Equipment $-







Scope of Work
Supplies $-







Travel $-







Method of Accountability
Deliverable Cost <enter description> $-







Other <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Subcontract Costs $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL DIRECT COSTS $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Indirect Rate








Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL INDIRECT COSTS $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONTRACT $-









































Basic Information Itemized Costs Justification






Name of Contractor
Salary and Wages $-







Method of Selection
Fringe Benefits $-







Justification for Sole Source Selection (if applicable)
Consultant Costs $-







Period of Performance
Equipment $-







Scope of Work
Supplies $-







Travel $-







Method of Accountability
Deliverable Cost <enter description> $-







Other <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Subcontract Costs $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL DIRECT COSTS $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Indirect Rate








Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL INDIRECT COSTS $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONTRACT $-









































Basic Information Itemized Costs Justification






Name of Contractor
Salary and Wages $-







Method of Selection
Fringe Benefits $-







Justification for Sole Source Selection (if applicable)
Consultant Costs $-







Period of Performance
Equipment $-







Scope of Work
Supplies $-







Travel $-







Method of Accountability
Deliverable Cost <enter description> $-







Other <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Subcontract Costs $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL DIRECT COSTS $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Indirect Rate








Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL INDIRECT COSTS $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONTRACT $-









































Basic Information Itemized Costs Justification






Name of Contractor
Salary and Wages $-







Method of Selection
Fringe Benefits $-







Justification for Sole Source Selection (if applicable)
Consultant Costs $-







Period of Performance
Equipment $-







Scope of Work
Supplies $-







Travel $-







Method of Accountability
Deliverable Cost <enter description> $-







Other <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Subcontract Costs $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL DIRECT COSTS $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Indirect Rate








Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL INDIRECT COSTS $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONTRACT $-









































Basic Information Itemized Costs Justification






Name of Contractor
Salary and Wages $-







Method of Selection
Fringe Benefits $-







Justification for Sole Source Selection (if applicable)
Consultant Costs $-







Period of Performance
Equipment $-







Scope of Work
Supplies $-







Travel $-







Method of Accountability
Deliverable Cost <enter description> $-







Other <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Subcontract Costs $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL DIRECT COSTS $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Indirect Rate








Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) TOTAL INDIRECT COSTS $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONTRACT $-








Sheet 4: Consultants


















Consultants























Basic Information Itemized Costs Justification






Name of Consultant
Number of Days of Consultation








Organizational Affiliation
Expected Daily Rate of Compensation $-







Nature of Services to Be Rendered
BASE COMPENSATION SUBTOTAL $-







Travel $-







Relevance of Service to the Project
Per Diem (total for all days consultation) $-







Supplies $-







Method of Accountability
Deliverable Cost <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) EXPENSES SUBTOTAL $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONSULTANT $-









































Basic Information Itemized Costs Justification






Name of Consultant
Number of Days of Consultation








Organizational Affiliation
Expected Daily Rate of Compensation $-







Nature of Services to Be Rendered
BASE COMPENSATION SUBTOTAL $-







Travel $-







Relevance of Service to the Project
Per Diem (total for all days consultation) $-







Supplies $-







Method of Accountability
Deliverable Cost <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) EXPENSES SUBTOTAL $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONSULTANT $-









































Basic Information Itemized Costs Justification






Name of Consultant
Number of Days of Consultation








Organizational Affiliation
Expected Daily Rate of Compensation $-







Nature of Services to Be Rendered
BASE COMPENSATION SUBTOTAL $-







Travel $-







Relevance of Service to the Project
Per Diem (total for all days consultation) $-







Supplies $-







Method of Accountability
Deliverable Cost <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) EXPENSES SUBTOTAL $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONSULTANT $-









































Basic Information Itemized Costs Justification






Name of Consultant
Number of Days of Consultation








Organizational Affiliation
Expected Daily Rate of Compensation $-







Nature of Services to Be Rendered
BASE COMPENSATION SUBTOTAL $-







Travel $-







Relevance of Service to the Project
Per Diem (total for all days consultation) $-







Supplies $-







Method of Accountability
Deliverable Cost <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) EXPENSES SUBTOTAL $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONSULTANT $-









































Basic Information Itemized Costs Justification






Name of Consultant
Number of Days of Consultation








Organizational Affiliation
Expected Daily Rate of Compensation $-







Nature of Services to Be Rendered
BASE COMPENSATION SUBTOTAL $-







Travel $-







Relevance of Service to the Project
Per Diem (total for all days consultation) $-







Supplies $-







Method of Accountability
Deliverable Cost <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Other <enter description> $-







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Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) EXPENSES SUBTOTAL $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONSULTANT $-









































Basic Information Itemized Costs Justification






Name of Consultant
Number of Days of Consultation








Organizational Affiliation
Expected Daily Rate of Compensation $-







Nature of Services to Be Rendered
BASE COMPENSATION SUBTOTAL $-







Travel $-







Relevance of Service to the Project
Per Diem (total for all days consultation) $-







Supplies $-







Method of Accountability
Deliverable Cost <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) EXPENSES SUBTOTAL $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONSULTANT $-









































Basic Information Itemized Costs Justification






Name of Consultant
Number of Days of Consultation








Organizational Affiliation
Expected Daily Rate of Compensation $-







Nature of Services to Be Rendered
BASE COMPENSATION SUBTOTAL $-







Travel $-







Relevance of Service to the Project
Per Diem (total for all days consultation) $-







Supplies $-







Method of Accountability
Deliverable Cost <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) EXPENSES SUBTOTAL $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONSULTANT $-









































Basic Information Itemized Costs Justification






Name of Consultant
Number of Days of Consultation








Organizational Affiliation
Expected Daily Rate of Compensation $-







Nature of Services to Be Rendered
BASE COMPENSATION SUBTOTAL $-







Travel $-







Relevance of Service to the Project
Per Diem (total for all days consultation) $-







Supplies $-







Method of Accountability
Deliverable Cost <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) EXPENSES SUBTOTAL $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONSULTANT $-









































Basic Information Itemized Costs Justification






Name of Consultant
Number of Days of Consultation








Organizational Affiliation
Expected Daily Rate of Compensation $-







Nature of Services to Be Rendered
BASE COMPENSATION SUBTOTAL $-







Travel $-







Relevance of Service to the Project
Per Diem (total for all days consultation) $-







Supplies $-







Method of Accountability
Deliverable Cost <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) EXPENSES SUBTOTAL $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONSULTANT $-









































Basic Information Itemized Costs Justification






Name of Consultant
Number of Days of Consultation








Organizational Affiliation
Expected Daily Rate of Compensation $-







Nature of Services to Be Rendered
BASE COMPENSATION SUBTOTAL $-







Travel $-







Relevance of Service to the Project
Per Diem (total for all days consultation) $-







Supplies $-







Method of Accountability
Deliverable Cost <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) EXPENSES SUBTOTAL $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONSULTANT $-









































Basic Information Itemized Costs Justification






Name of Consultant
Number of Days of Consultation








Organizational Affiliation
Expected Daily Rate of Compensation $-







Nature of Services to Be Rendered
BASE COMPENSATION SUBTOTAL $-







Travel $-







Relevance of Service to the Project
Per Diem (total for all days consultation) $-







Supplies $-







Method of Accountability
Deliverable Cost <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) EXPENSES SUBTOTAL $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONSULTANT $-









































Basic Information Itemized Costs Justification






Name of Consultant
Number of Days of Consultation








Organizational Affiliation
Expected Daily Rate of Compensation $-







Nature of Services to Be Rendered
BASE COMPENSATION SUBTOTAL $-







Travel $-







Relevance of Service to the Project
Per Diem (total for all days consultation) $-







Supplies $-







Method of Accountability
Deliverable Cost <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) EXPENSES SUBTOTAL $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONSULTANT $-









































Basic Information Itemized Costs Justification






Name of Consultant
Number of Days of Consultation








Organizational Affiliation
Expected Daily Rate of Compensation $-







Nature of Services to Be Rendered
BASE COMPENSATION SUBTOTAL $-







Travel $-







Relevance of Service to the Project
Per Diem (total for all days consultation) $-







Supplies $-







Method of Accountability
Deliverable Cost <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) EXPENSES SUBTOTAL $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONSULTANT $-









































Basic Information Itemized Costs Justification






Name of Consultant
Number of Days of Consultation








Organizational Affiliation
Expected Daily Rate of Compensation $-







Nature of Services to Be Rendered
BASE COMPENSATION SUBTOTAL $-







Travel $-







Relevance of Service to the Project
Per Diem (total for all days consultation) $-







Supplies $-







Method of Accountability
Deliverable Cost <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) EXPENSES SUBTOTAL $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONSULTANT $-









































Basic Information Itemized Costs Justification






Name of Consultant
Number of Days of Consultation








Organizational Affiliation
Expected Daily Rate of Compensation $-







Nature of Services to Be Rendered
BASE COMPENSATION SUBTOTAL $-







Travel $-







Relevance of Service to the Project
Per Diem (total for all days consultation) $-







Supplies $-







Method of Accountability
Deliverable Cost <enter description> $-







Allocation of Cost by Domain and Funding Category Other <enter description> $-







Funding Category

Domain
HDSP Diabetes NPAO SH Domain Total Other <enter description> $-







Basic Activities 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 2 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 3 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) Other <enter description> $-







Domain 4 Activities 0.0% 0.0% 0.0% 0.0% 0.0% ($0) EXPENSES SUBTOTAL $-







Funding Category Total 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) 0.0% ($0) TOTAL FOR CONSULTANT $-








Sheet 5: Basic Budget















Basic Funding
BUDGET FOR BASIC















Planned Budget Obligated to Date Expended to Date Unobligated Balance
Description of Indirect Cost Calculations
(also applies to enhanced domains)

Salary and Wages $-

$-


Fringe Benefits $-

$-

Consultant Costs $-

$-

Equipment $-

$-

Supplies $-

$-

Travel $-

$-

Other $-

$-

Contractual Costs $-

$-

Total Direct Costs $- $- $- $-

Indirect Costs





TOTAL $- $- $- $-

TARGET $-




DIFFERENCE (should be zero) $-
































Personnel Salary and Fringe










Totaled from Personnel Salary and Fringe tab (click to view) Total Salary and Wages Planned Total Fringe Planned










TOTAL: $- $-
























Consultant Costs











Totaled from Consultants tab (click to view) Total Amount Planned











TOTAL: $-

























Contractual Costs











Totaled from Contracts tab (click to view) Total Amount Planned











TOTAL: $-

























Equipment
In most cases, awardees may not use funds from this grant for the purchase of furniture or equipment. Select "Yes" at right if you plan to purchase equipment. Select
Item Requested Number Needed Unit Cost Amount Planned Justification



$-




$-




$-




$-




$-




$-




$-




$-




$-




$-




$-




$-




$-




$-




$-




$-




$-




$-




$-




$-

TOTAL: $-





























Supplies
Item Requested Type (if appropriate) Number Needed Unit Cost Amount Planned Justification




$-





$-





$-





$-





$-





$-





$-





$-





$-





$-





$-





$-





$-





$-





$-





$-





$-





$-





$-





$-

TOTAL: $-





























Travel
Description and Number of People Cost of Airfare or Mileage Cost of Per Diem or Lodging Cost of Ground Transportation Other Costs Total Amount Planned Justification





$-






$-






$-






$-






$-






$-






$-






$-






$-






$-






$-






$-






$-






$-






$-






$-






$-






$-






$-






$-

TOTAL: $- $- $- $- $-





























Other
Item Requested Number Needed Unit Cost Amount Planned Justification



$-




$-




$-




$-




$-




$-




$-




$-




$-




$-




$-




$-




$-




$-




$-




$-




$-




$-




$-




$-

TOTAL: $-


Sheet 6: Domain 2 Budget

















Domain 2: Environmental Approaches that Promote Health

BUDGET FOR DOMAIN 2


















Planned Budget Obligated to Date Expended to Date Unobligated Balance


Funding Category HDSP NPAO SH HDSP NPAO SH HDSP NPAO SH HDSP NPAO SH


Salary and Wages $- $- $-





$- $- $-


Fringe Benefits $- $- $-





$- $- $-


Consultant Costs $- $- $-





$- $- $-


Equipment $- $- $-





$- $- $-


Supplies $- $- $-





$- $- $-


Travel $- $- $-





$- $- $-


Other $- $- $-





$- $- $-


Contractual Costs $- $- $-





$- $- $-


Total Direct Costs $- $- $- $- $- $- $- $- $- $- $- $-


Indirect Costs








$- $- $-


TOTAL $- $- $- $- $- $- $- $- $- $- $- $-


TARGET $- $- $-











DIFFERENCE (should be zero) $- $- $-











































Personnel Salary and Fringe






Totaled from Personnel Salary and Fringe tab (click to view) Total Salary and Wages Planned Salary and Wages funded by HDSP Salary and Wages funded by NPAO Salary and Wages funded by SH Total Fringe Planned Fringe funded by HDSP Fringe funded by NPAO Fringe funded by SH






TOTAL: $- $- $- $- $- $- $- $-






















Consultant Costs










Totaled from Consultants tab (click to view) Total Amount Planned Amount funded by HDSP Amount funded by NPAO Amount funded by SH










TOTAL: $- $- $- $-



























Contractual Costs











Totaled from Contracts tab (click to view) Total Amount Planned Amount funded by HDSP Amount funded by NPAO Amount funded by SH











TOTAL: $- $- $- $-



























Equipment

In most cases, awardees may not use funds from this grant for the purchase of furniture or equipment. Select "Yes" at right if you plan to purchase equipment. Select

Item Requested Number Needed Unit Cost Amount Planned % allocated to HDSP activities Amount funded by HDSP % allocated to NPAO activities Amount funded by NPAO % allocated to SH activities Amount funded by SH Justification




$-
$-
$-
$-





$-
$-
$-
$-





$-
$-
$-
$-





$-
$-
$-
$-





$-
$-
$-
$-





$-
$-
$-
$-





$-
$-
$-
$-





$-
$-
$-
$-





$-
$-
$-
$-





$-
$-
$-
$-





$-
$-
$-
$-





$-
$-
$-
$-





$-
$-
$-
$-





$-
$-
$-
$-





$-
$-
$-
$-





$-
$-
$-
$-





$-
$-
$-
$-





$-
$-
$-
$-





$-
$-
$-
$-





$-
$-
$-
$-


TOTAL:


$-
$-
$-
$-




































Supplies

Item Requested Type (if appropriate) Number Needed Unit Cost Amount Planned % allocated to HDSP activities Amount funded by HDSP % allocated to NPAO activities Amount funded by NPAO % allocated to SH activities Amount funded by SH Justification





$-
$-
$-
$-






$-
$-
$-
$-






$-
$-
$-
$-






$-
$-
$-
$-






$-
$-
$-
$-






$-
$-
$-
$-






$-
$-
$-
$-






$-
$-
$-
$-






$-
$-
$-
$-






$-
$-
$-
$-






$-
$-
$-
$-






$-
$-
$-
$-






$-
$-
$-
$-






$-
$-
$-
$-






$-
$-
$-
$-






$-
$-
$-
$-






$-
$-
$-
$-






$-
$-
$-
$-






$-
$-
$-
$-






$-
$-
$-
$-


TOTAL: $-
$-
$-
$-




































Travel

Description and Number of People Cost of Airfare or Mileage Cost of Per Diem or Lodging Cost of Ground Transportation Other Costs Total Amount Planned % allocated to HDSP activities Amount funded by HDSP % allocated to NPAO activities Amount funded by NPAO % allocated to SH activities Amount funded by SH Justification






$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-


TOTAL: $- $- $- $- $-
$-
$-
$-




































Other

Item Requested Number Needed Unit Cost Amount Planned % allocated to HDSP activities Amount funded by HDSP % allocated to NPAO activities Amount funded by NPAO % allocated to SH activities Amount funded by SH Justification




$-
$-
$-
$-





$-
$-
$-
$-





$-
$-
$-
$-





$-
$-
$-
$-





$-
$-
$-
$-





$-
$-
$-
$-





$-
$-
$-
$-





$-
$-
$-
$-





$-
$-
$-
$-





$-
$-
$-
$-





$-
$-
$-
$-





$-
$-
$-
$-





$-
$-
$-
$-





$-
$-
$-
$-





$-
$-
$-
$-





$-
$-
$-
$-





$-
$-
$-
$-





$-
$-
$-
$-





$-
$-
$-
$-





$-
$-
$-
$-


TOTAL: $-
$-
$-
$-



Sheet 7: Domain 3 Budget


















Domain 3: Health System Interventions



BUDGET FOR DOMAIN 3





















Planned Budget Obligated to Date Expended to Date Unobligated Balance







Funding Category HDSP Diabetes HDSP Diabetes HDSP Diabetes HDSP Diabetes







Salary and Wages $- $-



$- $-







Fringe Benefits $- $-



$- $-







Consultant Costs $- $-



$- $-







Equipment $- $-



$- $-







Supplies $- $-



$- $-







Travel $- $-



$- $-







Other $- $-



$- $-







Contractual Costs $- $-



$- $-







Total Direct Costs $- $- $- $- $- $- $- $-







Indirect Costs





$- $-







TOTAL $- $- $- $- $- $- $- $-







TARGET $- $-













DIFFERENCE (should be zero) $- $-















































Personnel Salary and Fringe









Totaled from Personnel Salary and Fringe tab (click to view) Total Salary and Wages Planned Salary and Wages funded by HDSP Salary and Wages funded by Diabetes Total Fringe Planned Fringe funded by HDSP Fringe funded by Diabetes









TOTAL: $- $- $- $- $- $-


























Consultant Costs












Totaled from Consultants tab (click to view) Total Amount Planned Amount funded by HDSP Amount funded by Diabetes












TOTAL: $- $- $-





























Contractual Costs












Totaled from Contracts tab (click to view) Total Amount Planned Amount funded by HDSP Amount funded by Diabetes












TOTAL: $- $- $-





























Equipment



In most cases, awardees may not use funds from this grant for the purchase of furniture or equipment. Select "Yes" at right if you plan to purchase equipment. Select



Item Requested Number Needed Unit Cost Amount Planned % allocated to HDSP activities Amount funded by HDSP % allocated to Diabetes activities Amount funded by Diabetes Justification






$-
$-
$-







$-
$-
$-







$-
$-
$-







$-
$-
$-







$-
$-
$-







$-
$-
$-







$-
$-
$-







$-
$-
$-







$-
$-
$-







$-
$-
$-







$-
$-
$-







$-
$-
$-







$-
$-
$-







$-
$-
$-







$-
$-
$-







$-
$-
$-







$-
$-
$-







$-
$-
$-







$-
$-
$-







$-
$-
$-




TOTAL:


$-
$-
$-






































Supplies



Item Requested Type (if appropriate) Number Needed Unit Cost Amount Planned % allocated to HDSP activities Amount funded by HDSP % allocated to Diabetes activities Amount funded by Diabetes Justification







$-
$-
$-








$-
$-
$-








$-
$-
$-








$-
$-
$-








$-
$-
$-








$-
$-
$-








$-
$-
$-








$-
$-
$-








$-
$-
$-








$-
$-
$-








$-
$-
$-








$-
$-
$-








$-
$-
$-








$-
$-
$-








$-
$-
$-








$-
$-
$-








$-
$-
$-








$-
$-
$-








$-
$-
$-








$-
$-
$-




TOTAL: $-
$-
$-






































Travel



Description and Number of People Cost of Airfare or Mileage Cost of Per Diem or Lodging Cost of Ground Transportation Other Costs Total Amount Planned % allocated to HDSP activities Amount funded by HDSP % allocated to Diabetes activities Amount funded by Diabetes Justification








$-
$-
$-









$-
$-
$-









$-
$-
$-









$-
$-
$-









$-
$-
$-









$-
$-
$-









$-
$-
$-









$-
$-
$-









$-
$-
$-









$-
$-
$-









$-
$-
$-









$-
$-
$-









$-
$-
$-









$-
$-
$-









$-
$-
$-









$-
$-
$-









$-
$-
$-









$-
$-
$-









$-
$-
$-









$-
$-
$-




TOTAL: $- $- $- $- $-
$-
$-






































Other



Item Requested Number Needed Unit Cost Amount Planned % allocated to HDSP activities Amount funded by HDSP % allocated to Diabetes activities Amount funded by Diabetes Justification






$-
$-
$-







$-
$-
$-







$-
$-
$-







$-
$-
$-







$-
$-
$-







$-
$-
$-







$-
$-
$-







$-
$-
$-







$-
$-
$-







$-
$-
$-







$-
$-
$-







$-
$-
$-







$-
$-
$-







$-
$-
$-







$-
$-
$-







$-
$-
$-







$-
$-
$-







$-
$-
$-







$-
$-
$-







$-
$-
$-




TOTAL: $-
$-
$-





Sheet 8: Domain 4 Budget




















Domain 4: Community-Clinical Linkages



BUDGET FOR DOMAIN 4























Planned Budget Obligated to Date Expended to Date Unobligated Balance





Funding Category HDSP Diabetes SH HDSP Diabetes SH HDSP Diabetes SH HDSP Diabetes SH





Salary and Wages $- $- $-





$- $- $-





Fringe Benefits $- $- $-





$- $- $-





Consultant Costs $- $- $-





$- $- $-





Equipment $- $- $-





$- $- $-





Supplies $- $- $-





$- $- $-





Travel $- $- $-





$- $- $-





Other $- $- $-





$- $- $-





Contractual Costs $- $- $-





$- $- $-





Total Direct Costs $- $- $- $- $- $- $- $- $- $- $- $-





Indirect Costs








$- $- $-





TOTAL $- $- $- $- $- $- $- $- $- $- $- $-





TARGET $- $- $-














DIFFERENCE (should be zero) $- $- $-




















































Personnel Salary and Fringe









Totaled from Personnel Salary and Fringe tab (click to view) Total Salary and Wages Planned Salary and Wages funded by HDSP Salary and Wages funded by Diabetes Salary and Wages funded by SH Total Fringe Planned Fringe funded by HDSP Fringe funded by Diabetes Fringe funded by SH









TOTAL: $- $- $- $- $- $- $- $-




























Consultant Costs













Totaled from Consultants tab (click to view) Total Amount Planned Amount funded by HDSP Amount funded by Diabetes Amount funded by SH













TOTAL: $- $- $- $-
































Contractual Costs













Totaled from Contracts tab (click to view) Total Amount Planned Amount funded by HDSP Amount funded by Diabetes Amount funded by SH













TOTAL: $- $- $- $-
































Equipment



In most cases, awardees may not use funds from this grant for the purchase of furniture or equipment. Select "Yes" at right if you plan to purchase equipment. Select



Item Requested Number Needed Unit Cost Amount Planned % allocated to HDSP activities Amount funded by HDSP % allocated to Diabetes activities Amount funded by Diabetes % allocated to SH activities Amount funded by SH Justification






$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-




TOTAL:


$-
$-
$-
$-










































Supplies



Item Requested Type (if appropriate) Number Needed Unit Cost Amount Planned % allocated to HDSP activities Amount funded by HDSP % allocated to Diabetes activities Amount funded by Diabetes % allocated to SH activities Amount funded by SH Justification







$-
$-
$-
$-








$-
$-
$-
$-








$-
$-
$-
$-








$-
$-
$-
$-








$-
$-
$-
$-








$-
$-
$-
$-








$-
$-
$-
$-








$-
$-
$-
$-








$-
$-
$-
$-








$-
$-
$-
$-








$-
$-
$-
$-








$-
$-
$-
$-








$-
$-
$-
$-








$-
$-
$-
$-








$-
$-
$-
$-








$-
$-
$-
$-








$-
$-
$-
$-








$-
$-
$-
$-








$-
$-
$-
$-








$-
$-
$-
$-




TOTAL: $-
$-
$-
$-










































Travel



Description and Number of People Cost of Airfare or Mileage Cost of Per Diem or Lodging Cost of Ground Transportation Other Costs Total Amount Planned % allocated to HDSP activities Amount funded by HDSP % allocated to Diabetes activities Amount funded by Diabetes % allocated to SH activities Amount funded by SH Justification








$-
$-
$-
$-









$-
$-
$-
$-









$-
$-
$-
$-









$-
$-
$-
$-









$-
$-
$-
$-









$-
$-
$-
$-









$-
$-
$-
$-









$-
$-
$-
$-









$-
$-
$-
$-









$-
$-
$-
$-









$-
$-
$-
$-









$-
$-
$-
$-









$-
$-
$-
$-









$-
$-
$-
$-









$-
$-
$-
$-









$-
$-
$-
$-









$-
$-
$-
$-









$-
$-
$-
$-









$-
$-
$-
$-









$-
$-
$-
$-




TOTAL: $- $- $- $- $-
$-
$-
$-










































Other



Item Requested Number Needed Unit Cost Amount Planned % allocated to HDSP activities Amount funded by HDSP % allocated to Diabetes activities Amount funded by Diabetes % allocated to SH activities Amount funded by SH Justification






$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-







$-
$-
$-
$-




TOTAL: $-
$-
$-
$-





Sheet 9: Budget Reports









Budget Reports
PPHF Budget








Target versus Planned Budget by Domain and Funding Category

Funding Category Heart Disease and Stroke Prevention Diabetes Nutrition, Physical Activity, and Obesity School Health TOTAL
Target Funding Basic $- $- $- $- $-
Enhanced $- $- $- $- $-
Domain 2 $- $- $- $- $-
Domain 3 $- $- $- $- $-
Domain 4 $- $- $- $- $-
TOTAL TARGET $- $- $- $- $-
Planned Budget Basic $- $- $- $- $-
Enhanced $- $- $- $- $-
Domain 2 $- $- $- $- $-
Domain 3 $- $- $- $- $-
Domain 4 $- $- $- $- $-
TOTAL PLANNED $- $- $- $- $-
Balance
(Not Yet Planned)
Basic $- $- $- $- $-
Enhanced $- $- $- $- $-
Domain 2 $- $- $- $- $-
Domain 3 $- $- $- $- $-
Domain 4 $- $- $- $- $-
NET BALANCE $- $- $- $- $-
























Planned Budget by Object Class and Funding Category









Basic Component






Funding Category

Object Class HDSP Diabetes NPAO SH TOTAL

Salary and Wages $- $- $- $- $-

Fringe Benefits $- $- $- $- $-

Consultant Costs $- $- $- $- $-

Equipment $- $- $- $- $-

Supplies $- $- $- $- $-

Travel $- $- $- $- $-

Other $- $- $- $- $-

Contractual Costs $- $- $- $- $-

Indirect Costs $- $- $- $- $-

TOTAL $- $- $- $- $-









Enhanced Component






Funding Category

Object Class HDSP Diabetes NPAO SH TOTAL

Salary and Wages $- $- $- $- $-

Fringe Benefits $- $- $- $- $-

Consultant Costs $- $- $- $- $-

Equipment $- $- $- $- $-

Supplies $- $- $- $- $-

Travel $- $- $- $- $-

Other $- $- $- $- $-

Contractual Costs $- $- $- $- $-

Indirect Costs $- $- $- $- $-

TOTAL $- $- $- $- $-

Sheet 10: 424A-SectionB_PPHF

Form 424A, Section B
PPHF Funding







Object Class Categories Funding Category TOTAL Enhanced (sum of C-F) TOTAL Award (Basic & Enhanced)
(sum of B and G)

Basic
(HDSP, Diabetes, NPAO)
Enhanced
Heart Disease & Stroke Prev
Enhanced
Diabetes

a. Personnel $- $- $- $- $-
b. Fringe Benefits $- $- $- $- $-
c. Travel $- $- $- $- $-
d. Equipment $- $- $- $- $-
e. Supplies $- $- $- $- $-
f. Contractual $- $- $- $- $-
g. Construction $- $- $- $- $-
h. Other $- $- $- $- $-
i. Total Direct Charges (sum of a-h) $- $- $- $- $-
j. Indirect Charges $- $- $- $- $-
k. TOTALS (sum of i and j) $- $- $- $- $-

Sheet 11: 424A-SectionB_Non-PPHF

Form 424A, Section B
Non-PPHF Funding








Object Class Categories Funding Category TOTAL Enhanced (sum of C-F) TOTAL Award (Basic & Enhanced)
(sum of B and G)
Basic
(SH)
Enhanced
Heart Disease & Stroke Prev
Enhanced
Diabetes
Enhanced
School Health
Enhanced
Nutrition, PA & Obesity
a. Personnel $- $- $- $- $- $- $-
b. Fringe Benefits $- $- $- $- $- $- $-
c. Travel $- $- $- $- $- $- $-
d. Equipment $- $- $- $- $- $- $-
e. Supplies $- $- $- $- $- $- $-
f. Contractual $- $- $- $- $- $- $-
g. Construction $- $- $- $- $- $- $-
h. Other $- $- $- $- $- $- $-
i. Total Direct Charges (sum of a-h) $- $- $- $- $- $- $-
j. Indirect Charges $- $- $- $- $- $- $-
k. TOTALS (sum of i and j) $- $- $- $- $- $- $-

Sheet 12: In-Kind Funding (Optional)








In-Kind Funding (Optional)







Total non-Federal Funds (if not using table below)










Estimated In-Kind Funding
Object Class Applicant Funds State Funds Local Funds Other Program Income TOTAL
Salary and Wages




$-
Fringe Benefits




$-
Consultant Costs




$-
Equipment




$-
Supplies




$-
Travel




$-
Other




$-
Contractual Costs




$-
TOTAL $- $- $- $- $- $-







You may use the space below to provide additional detail on in-kind and matching funds provided.
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