18 Form 3A - clean

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
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: 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 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 14N136B, Rockville, Maryland, 20857 or [email protected].