Form 1B: Funding Request Summary

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             OMB No.: 0915-0285. Expiration Date: 6/30/2029
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



Note the following when completing this form:
    • Before completing Form 1B, the SF-424A: Budget Information form must be completed.
    • The Federal Funding Request below matches the Total Federal Funds requested on the SF-424A.Go to Section A – Budget Summary in the Budget Information form to edit the Total Federal Funds requested, not to exceed $650,000.
    • The one-time funding request below totals the Equipment and Construction (minor A/R) federal line items on the SF-424A. Go to Section B – Budget Categories in the Budget Information form to edit the federal funds requested for Equipment and Construction (minor A/R).
    • Equipment includes moveable items that are non-expendable, tangible personal property (including information technology systems) having a useful life of more than one year and a per-unit acquisition cost which equals or exceeds the lesser of 
        a. the capitalization level established by the applicant for its financial statement purposes, or 
        b. $10,000. 
    • Equipment that does not meet the $10,000 per unit cost threshold should be considered Supplies.
    • Moveable equipment can be readily shifted from place to place without requiring a change in the utilities or structural characteristics of the space. Permanently affixed equipment (e.g., heating, ventilation, and air conditioning (HVAC), generators, and lighting) is considered fixed equipment and is categorized as minor A/R (not equipment).
        ◦ Licenses for electronic health records or health information technology should be reported in “Other Costs” in your budget, not considered equipment.
NAP Federal Funding Request
Will pre-populate from Budget Information form, Section A 
One-time Funding Request 
You indicated on the Budget Information form, Section B that you are requesting NAP one-time funding for:
[   ] N/A (no funding requested for equipment or minor A/R)
[   ] Equipment (no minor A/R)
[   ] Minor alteration/renovation with equipment
[   ] Minor alteration/renovation without equipment 

NAP one-time funding request for minor A/R and equipment: <amount will pre-populate from Budget Information form, Section B >
NOTE: 
    • If no funding is requested for equipment or minor A/R in the Budget Information form, the following forms will not be available in your application: Equipment List, A/R Project Cover Page, and Other Requirements for Sites.
    • If 'Equipment (no minor A/R)’ is indicated above, you must complete the Equipment List form.
    • If 'Minor A/R with equipment' is indicated above, you must complete the Equipment List, A/R Project Cover Page, and Other Requirements for Sites forms.
    • If 'Minor A/R without equipment' is indicated above, you must complete the A/R Project Cover Page and Other Requirements for Sites forms.
Based on your one-time funding request, 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 Budget Information Form to remove equipment or construction line items, the system will delete information from all forms that are no longer applicable.

Health centers (section 330 grant funded and Federally Qualified Health Center look-alikes) are patient-directed organizations that deliver affordable, accessible, quality, and cost-effective primary health care services to patients and adjust fees based on income and family size. 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. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0915-0285 and it is valid until 06/30/2026. 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 0.75 hours 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 Information Collection Clearance Officer, 5600 Fishers Lane, Room 13N82, Rockville, Maryland, 20857 or [email protected].  Please see https://www.hrsa.gov/about/508-resources for the HRSA digital accessibility statement.