Form 1B BPHC Funding Request Summary

OMB No.: 0915-0285 Expiration Date: XX/XX/20XX

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration FORM 1B: BPHC FUNDING REQUEST SUMMARY	FOR HRSA USE ONLY
	Application Tracking Number	Grant Number

NOTES: • Before completing Form 1B, the SF-424A: Budget Information form must be completed. The one-time funding request on Form 1B must be consistent with the SF-424A Construction and Equipment line items. • If you select 'Equipment only' option in 'One-time funds will be used for' section below, you will be required to provide information in following form: Equipment List. • If you select 'Minor alteration/renovation with equipment' option in 'One-time funds will be used for' section below, you will be required to provide information in following forms: Equipment List, Alteration/Renovation (A/R) Project Cover Page and Other Requirements for Sites. • If you select 'Minor alteration/renovation without equipment' option in 'One-time funds will be used for' section below, you will be required to provide information in following forms: Alteration/Renovation (A/R) Project Cover Page and Other Requirements for Sites. • If you select 'N/A' option in 'One-time funds will be used for' section below, you must not provide any information in following forms: Equipment List, Alteration/Renovation (A/R) Project Cover Page and Other Requirements for Sites.
View Resources Refer to Section A – Budget Summary in Budget Information form to view the Total Federal Funds requested for Year 1. Refer to Section E – Budget Estimates Of Federal Funds Needed For Balance Of The Project in Budget Information form to view the Total Federal Funds requested for Year 2. Refer to Section B – Budget Categories in Budget Information form to view the Federal funds requested for Equipment and Construction (A/R).
Federal Funds Requested: Based on a 12-month Budget for each Budget Period
Type of Health Center	Program	Year 1	Year 2		Year 3	Year 4	Year 5
		Operational	Operational	Funding Population Percentage	Operational	Operational	Operational
Community Health Centers	CHC-330(e)		Pre-populated	Auto-calculated	$0.00	$0.00	$0.00
Health Care for the Homeless	HCH-330(h)		Pre-populated	Auto-calculated	$0.00	$0.00	$0.00
Migrant Health Centers	MHC-330(g)		Pre-populated	Auto-calculated	$0.00	$0.00	$0.00
Public Housing Primary Care	PHPC-330(i)		Pre-populated	Auto-calculated	$0.00	$0.00	$0.00
Total Operational Costs			Pre-populated	Auto-calculated	$0.00	$0.00	$0.00
One-Time Funding			N/A		$0.00	$0.00	$0.00
Total Federal Funding Request		Auto-calculated	Auto-calculated	N/A	$0.00	$0.00	$0.00

NOTE: If you indicate below that you are using one-time funds for A/R, you will be required to complete the applicable Site forms. After providing information in Form 5B, Equipment List, A/R Project Cover Page, or Other Requirements for Sites forms, if you choose to update the selected option displayed below, the system will delete information from all the forms that are not applicable.

One-time funds will be used for:

[_] Equipment only
[_] Minor alteration/renovation with equipment
[_] Minor alteration/renovation without equipment
[_] N/A

Public Burden Statement: 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 project is 0915-0285. Public reporting burden for this collection of information is estimated to average 1 hour45 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 14N0-393, Rockville, Maryland, 20857