Form 14 Form 1B - clean

OMB No.: 0915-0285. Expiration Date: X/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 Total 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 Budget Information form to edit the Total Federal Funds requested for Year 1. The 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 Budget Information form to edit the Federal funds requested for Equipment and Construction (minor A/R). Go to Section E – Budget Estimates Of Federal Funds Needed For Balance Of The Project in Budget Information form to edit the Total Federal Funds requested for Year 2.
Federal Funds Requested: Based on a 12-month Budget for each Budget Period
Type of Health Center Program	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		100%
NOTES: If you select 'N/A' below, the following forms will not be available in your application: Equipment List, A/R Project Cover Page, and Other Requirements for Sites. If you select 'Equipment only' below, you must include the equipment amount in the equipment line item in Section B – Budget Categories on the Budget Information form and complete the Equipment List form. 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 Section B – Budget Categories on the Budget Information form and complete the Equipment List form, A/R Project Cover Page, and Other Requirements for Sites form. If you select 'Minor alteration/renovation without equipment' below, you must include the minor A/R amount in the construction line item in Section B – Budget Categories on the Budget Information form and complete the A/R Project Cover Page and Other Requirements for Sites form
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: If 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 delete information from all one-time funding forms that are no longer applicable.

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. The Health Center Program application forms provide essential information to HRSA staff and objective review committee panels for application evaluation; funding recommendation and approval; designation; and monitoring. The OMB control number for this information collection is 0915-0285 and it is valid until XX/XX/XXXX. This information collection is mandatory under the Health Center Program authorized by section 330 of the Public Health Service (PHS) Act (42 U.S.C. 254b). Public reporting burden for this collection of information is estimated to average 45 minutes 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 14N136B, Rockville, Maryland, 20857 or [email protected].