15 Funding Request Summary Form

OMB No.: 0915-0285. Expiration Date: 3/31/2023

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration FUNDING REQUEST SUMMARY FORM
Note the following when completing this form: Before completing this form, the SF-424A: Budget Information form must be completed. If needed, go to Section A – Budget Summary in the Budget Information form to edit the Total Federal Funds requested, not to exceed $500,000. If needed, go to Section B – Budget Categories in the Budget Information form to edit the Federal funds requested for Equipment and Construction (minor A/R).
SBHC Total Federal Funding Request	Will pre-populate from Budget Information form, Section A
For your SBHC location proposed on the SBHC Location form, you will provide the requested information. Equipment and Minor Alteration/Renovation (A/R) Funding: Indicate whether you are requesting SBHC funding for ‘Equipment (no minor A/R)’, ‘Minor alteration/renovation with equipment’, ‘Minor alteration/renovation without equipment’, or none of these for your proposed SBHC location. If you select 'Equipment (no minor A/R)’ below, you must include the total 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 A/R with equipment' below, you must include the total 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 A/R without equipment' below, you must include the total 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. 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. NOTE: Based on your selection, the system will require you to complete the applicable equipment and/or minor A/R forms. After providing required information in the relevant forms, if you change the selected option on this form, the system will delete information from all forms that are no longer applicable.
Equipment and Minor Alteration/Renovation (A/R) Funding
Indicate below if you are requesting SBHC funding for: [ ] Equipment (no minor A/R) [ ] Minor alteration/renovation with equipment [ ] Minor alteration/renovation without equipment [ ] N/A (no funding requested for equipment or minor A/R)

Public Burden Statement: The OMB control number for this information collection is 0915-0285 and it is valid until 3/31/2023. Public reporting burden for this collection of information is estimated to average 30 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].