18E Form 3A - edits

The Health Center Program Application Forms

Form 3A - edits

OMB: 0915-0285

Document [docx]
Download: docx | pdf

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

LAL 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

  1. Expenses

  1. Personnel






  1. Fringe Benefits






  1. Travel






  1. Equipment






  1. Supplies






  1. Contractual






  1. Construction






  1. Other






  1. Total Direct Charges

(sum of a through h)

will auto-calculate in EHB






  1. Indirect Charges






  1. Total Expenses

(sum of i and j) 

will auto-calculate in EHB






  1. Revenue

  1. Applicant






  1. Federal






  1. State






  1. Local






  1. Other






  1. Program Income






  1. Total Revenue

(sum of a through f) 

will auto-calculate in EHB






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
AuthorSurbhi Taori
File Modified0000-00-00
File Created2023-08-27

© 2024 OMB.report | Privacy Policy