Document
Funding Sources
ICR 202610-0915-001 · OMB 0915-0285 · Object 174057800.
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Document Metadata
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
|---|---|
| File Title | Funding Sources |
| Last Modified By | Writer |
| File Modified | 2026-09-23 |
| File Created | 2026-10-22 |
| Conversion State | complete |
Extracted Text
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration
FUNDING SOURCES
FOR HRSA USE ONLY
Application Tracking Number
Grant Number
Project Number
Project Type
Project Title
Funding Sources Information
Applicant Name
1. Total Project Cost (From cell 16a of SF424C)
2. Federal Assistance requested (From cell 17c of SF424C)
3. Other Funding Sources
Amount Secured
(a)
Amount Expected
(b)
Amount Forthcoming
(c)
Total
(d = a + b + c)
3a. State Grants
3b. Local Funding
3c. Other Federal Funding
3d. Private/Third Party Funding
3e. Other Project Financing
Total Other Funding Sources
Public Burden Statement: 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 06/30/2029. 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 0.5 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.