3A Look Alike Budget Information Final

OMB No.: 0915-0285 Expiration Date: XX/XX/20XX

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration FORM 3A: LOOK-ALIKE BUDGET INFORMATION				FOR HRSA USE ONLY
				Grant Number		Application Tracking Number
Note: The program income total on this form must match the program income total on Form 3.
Budget Category	Community Health Centers (CHC - 330(e))	Migrant Health Centers (MHC - 330(g))	Health Care for the Homeless (HCH - 330(h))		Public Housing Primary Care (PHPC - 330(i))		Total will auto-calculate in EHB
Expenses
Personnel
Fringe Benefits
Travel
Equipment
Supplies
Contractual
Construction
Other
Total Direct Charges (sum of a through h) will auto-calculate in EHB
Indirect Charges
Total Expenses (sum of i and j)  will auto-calculate in EHB
Revenue
Applicant
Federal
State
Local
Other
Program Income
Total Revenue (sum of a through f)  will auto-calculate in EHB

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915-0285. Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N-39, Rockville, Maryland, 20857

INSTRUCTIONS

Form 3A collects the budget information for the look-alike project.

In Part 1: Expenses, enter the projected first year of expenses for each Health Center Program type for which designation is requested (i.e., CHC, MHC, HCH, PCPH). The total fields are calculated automatically when you save the form.

In Part 2: Revenue, enter the projected first year of revenue by funding source (applicant, Federal, State, local, and/or other sources). The total fields are calculated automatically when you save the form.

Form 3A should be consistent with amounts justified in the budget justification narrative.