3-Project Budget and Funding Sources Worksheet.docx
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- New Mexico
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This is a Project Budget and Funding Sources Worksheet issued by the Aging and Long Term Services Department (ALTSD) of New Mexico for senior centers applying for capital outlay funding under the 2028 Capital Outlay Application for New Construction. The worksheet is designed to be completed for all application types, with one worksheet required per project. Applicants must provide comprehensive project information including the senior center facility name, fiscal agent, application type, project title, ICIP project title with priority and fiscal year designation, amount requested, and total project cost. The budget section requires itemization of up to ten budget categories or line items, with corresponding amounts for capital outlay requests and other funding sources supported by quotes or estimates. No specific response dates, due dates, site visits, bidder conferences, or award dates are identified in this template document.
The worksheet requires applicants to identify all funding sources and their status, including capital outlay requests, local government or fiscal-agent funds, tribal funds, state funds, federal funds, grants or donor funds, and other sources. Applicants must certify that total funding equals total project budget and identify any remaining funding gaps with expected sources and availability dates. The budget must align with project scope and supporting documentation, and applicants must identify costs not included in the budget and their funding mechanisms. An authorized representative must sign and date the certification, confirming the budget is complete and accurate, aligns with supporting quotes and estimates, identifies all known sources, and includes all costs necessary to complete the project or identifies any remaining gap.
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Other files
| File | Type | Posted |
|---|---|---|
| 2-Scope of Work and Deliverables Schedule Worksheet.docx | DOCX document | |
| 1-Certification Letter.docx | DOCX document |
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Text version
Project Budget and Funding Sources Worksheet Use for all application types. Complete one worksheet per project. Amounts must align with project scope and supporting documentation.
Project Information
| Field |
| Applicant response |
Senior Center Facility Name
Fiscal Agent
Application Type
Project Title
ICIP Project Title / Priority / Fiscal Year
| Amount Requested |
| $ |
| Total Project Cost |
| $ |
Project Manager / Contact
Project Budget
| No. |
| Budget Category / Line Item |
| Description |
| Amount |
| Capital Outlay Request |
| Other Funding |
| Quote/Estimate Ref. |
| $ |
| $ |
| $ |
| $ |
| $ |
| $ |
| $ |
| $ |
| $ |
| $ |
| $ |
| $ |
| $ |
| $ |
| $ |
| $ |
| $ |
| $ |
| $ |
| $ |
| $ |
| $ |
| $ |
| $ |
| $ |
| $ |
| $ |
| $ |
| $ |
| $ |
Total Project Budget
| $ |
| $ |
| $ |
Funding Sources
| Funding Source |
| Amount |
| Status |
| Date Available |
| Restrictions / Notes |
| Capital Outlay requested |
| $ |
| Requested |
| Local government / fiscal-agent funds |
| $ |
| Secured / Pending |
| Tribal funds |
| $ |
| Secured / Pending |
| State funds |
| $ |
| Secured / Pending |
| Federal funds |
| $ |
| Secured / Pending |
| Grant / donor / other funds |
| $ |
| Secured / Pending |
| Other: |
| $ |
| Secured / Pending |
| Total Funding Sources |
| $ |
Budget Completion and Advance-Funding Confirmation Does the total funding equal the total project budget? Yes / No If no, identify remaining funding gap, expected source, and date available:
Identify costs not included and how they will be funded:
Identify the fiscal-agent fund, reserve, appropriation, or other source used to pay allowable costs before reimbursement:
Budget Certification I certify that this budget is complete and accurate to the best of my knowledge; aligns with quotes, estimates, and scope; identifies all known sources; and includes costs necessary to complete the project or identifies any remaining gap.
Authorized Representative Name: ______________________________________________________________________ Title: ______________________________________________________________________ Signature: ______________________________________________________________________ Date: ______________________________________________________________________
Final Consolidated Senior Center Capital Outlay Application Question Sets | Page 1
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