14E Form 1B - editsX

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

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
NOTES: • Before completing Form 1B, the SF-424A: Budget Information form must be completed. • The form to edit the Total Federal Funds requested for Year 1.Budget InformationTotal Federal Funding Request for Year 1 on Form 1B must match the Total Federal Funds requested for Year 1 on the SF-424A. Go to Section A – Budget Summary in • form to edit the Federal funds requested for Equipment and Construction (minor A/R).Budget InformationThe one-time funding request on Form 1B must total the Equipment and Construction (minor A/R) line items on the SF-424A. Go to Section B – Budget Categories in • form to edit the Total Federal Funds requested for Year 2. Budget InformationGo to Section E – Budget Estimates Of Federal Funds Needed For Balance Of The Project in
Federal Funds Requested: Based on a 12-month Budget for each Budget Period
Type of Health Center		Year 1	Year 2
		Operational	Operational Will pre-populate from Budget Summary		Funding Population Percentage Will auto-calculate in EHB
Community Health Centers			Pre-populated		Auto-Calculated
Health Care for the Homeless			Pre-populated		Auto-Calculated
Migrant Health Centers			Pre-populated		Auto-Calculated
Public Housing Primary Care			Pre-populated		Auto-Calculated
Total Operational Costs		Will auto-calculate in EHB	Pre-populated		Auto-Calculated
One-Time Funding			N/A		N/A
Total Federal Funding Request		Will auto-calculate in EHB	Will auto-calculate in EHB		N/A
NOTES: If you select A' below, the following forms will not be available in your application: Equipment List, A/R Project Cover Page, and Other Requirements for Sites.'N/ If you select 'Equipment only' below, you must include the equipment amount in the equipment line item in and complete the Equipment List form. formBudget InformationSection B – Budget Categories on the If you select 'Minor alteration/renovation with equipment' below, you must include the minor A/R amount in the construction line item and the equipment amount in the equipment line item in and complete the Equipment List form, A/R Project Cover Page, and Other Requirements for Sites form. formBudget InformationSection B – Budget Categories on the If you select 'Minor alteration/renovation without equipment' below, you must include the minor A/R amount in the construction line item in and complete the A/R Project Cover Page and Other Requirements for Sites form formBudget InformationSection B – Budget Categories on the
One-Time Funding Request Indicate below if you are requesting one-time funding in year 1 for equipment and/or minor alteration/renovation (A/R).
One-time funds will be used for: [ _ ] N/A [ _ ] Minor alteration/renovation without equipment [ _ ] Minor alteration/renovation with equipment [ _ ] Equipment only NOTE: information from all one-time funding forms that are no longer applicable.deleteIf you indicate that you are requesting one-time funds, the system will require you to complete the applicable equipment and/or minor A/R forms. After providing required information in the relevant one-time funding forms, if you change the selected option above, the system will

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. . paperwork@hrsa.gov HYPERLINK "https://sharepoint.hrsa.gov/sites/bphc/oppd/ED1/OMB%20Forms%20Approval%202020/paperwork@hrsa.gov" 42 U.S.C. 254b HYPERLINK "http://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section254b&num=0&edition=prelim"