14E Form 1B - editsX

The Health Center Program Application Forms

Form 1B - edits.DOCX

Form 1B: BPHC Funding Request Summary

OMB: 0915-0285

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration

Form 1B: FUNDING REQUEST SUMMARY

FOR HRSA USE ONLY

Grant Number

Application Tracking Number



NOTES:
• Before completing Form 1B, the SF-424A: Budget Information form must be completed.


The form to edit the Total Federal Funds requested for Year 1.Budget InformationTotal Federal Funding Request for Year 1 on Form 1B must match the Total Federal Funds requested for Year 1 on the SF-424A. Go to Section A – Budget Summary in

form to edit the Federal funds requested for Equipment and Construction (minor A/R).Budget InformationThe one-time funding request on Form 1B must total the Equipment and Construction (minor A/R) line items on the SF-424A. Go to Section B – Budget Categories in

form to edit the Total Federal Funds requested for Year 2. Budget InformationGo to Section E – Budget Estimates Of Federal Funds Needed For Balance Of The Project in









Federal Funds Requested: Based on a 12-month Budget for each Budget Period

Type of Health Center


Year 1

Year 2

Operational

Operational

Will pre-populate from Budget Summary

Funding Population Percentage

Will auto-calculate in EHB

Community Health Centers



Pre-populated

Auto-Calculated

Health Care for the Homeless



Pre-populated

Auto-Calculated

Migrant Health Centers



Pre-populated

Auto-Calculated

Public Housing Primary Care



Pre-populated

Auto-Calculated

Total Operational Costs

Will auto-calculate in EHB

Pre-populated

Auto-Calculated

One-Time Funding


N/A

N/A

Total Federal Funding Request


Will auto-calculate in EHB

Will auto-calculate in EHB

N/A

NOTES:

  • If you select A' below, the following forms will not be available in your application: Equipment List, A/R Project Cover Page, and Other Requirements for Sites.'N/

  • If you select 'Equipment only' below, you must include the equipment amount in the equipment line item in and complete the Equipment List form. formBudget InformationSection B – Budget Categories on the

  • If you select 'Minor alteration/renovation with equipment' below, you must include the minor A/R amount in the construction line item and the equipment amount in the equipment line item in and complete the Equipment List form, A/R Project Cover Page, and Other Requirements for Sites form. formBudget InformationSection B – Budget Categories on the

  • If you select 'Minor alteration/renovation without equipment' below, you must include the minor A/R amount in the construction line item in and complete the A/R Project Cover Page and Other Requirements for Sites form formBudget InformationSection B – Budget Categories on the

One-Time Funding Request

Indicate below if you are requesting one-time funding in year 1 for equipment and/or minor alteration/renovation (A/R).

One-time funds will be used for:

[ _ ] N/A

[ _ ] Minor alteration/renovation without equipment


[ _ ] Minor alteration/renovation with equipment

[ _ ] Equipment only


NOTE: information from all one-time funding forms that are no longer applicable.deleteIf you indicate that you are requesting one-time funds, the system will require you to complete the applicable equipment and/or minor A/R forms. After providing required information in the relevant one-time funding forms, if you change the selected option above, the system will


Public Burden Statement: Health centers (section 330 grant funded and Federally Qualified Health Center look-alikes) deliver comprehensive, high quality, cost-effective primary health care to patients regardless of their ability to pay. . [email protected] HYPERLINK "https://sharepoint.hrsa.gov/sites/bphc/oppd/ED1/OMB%20Forms%20Approval%202020/[email protected]" 42 U.S.C. 254b HYPERLINK "http://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section254b&num=0&edition=prelim"








File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleForm 1B
AuthorSurbhi Taori
File Modified0000-00-00
File Created2021-01-13

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