ADSD_Budget_Template_Form~8.xlsx

XLSX spreadsheet 225 KB Posted

Attached to
ADSD Notice of Funding Opportunity - Opening Minds through Art - Dementia Support
Solicitation number
40DHHS-S3930
Issued by
Nevada

About this file

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This is a budget template form issued by the Nevada Aging and Disability Services Division (ADSD) for subaward applications related to the Opening Minds through Art (OMA) program, an evidence-based intergenerational art program for people living with dementia. The template is designed to capture comprehensive budget information for qualified organizations implementing this program, with detailed sections for personnel costs, travel expenses, operating costs, equipment purchases, contractual services, and indirect costs. The form requires applicants to provide specific details including staff positions with Position Control Numbers (PCNs), annual salaries, fringe benefit rates, percentage of time allocated to direct services, and descriptions of position duties as they relate to program objectives. Travel expenses must be itemized by trip type (in-state and out-of-state), with justifications tied to program goals, utilizing GSA rates for per diem, lodging, and mileage unless the organization's policies specify lower rates.

The budget template accommodates multiple funding sources and requires applicants to identify whether funding is secured or pending, with a mandatory match requirement unless waived by ADSD per the Notice of Funding Opportunity. Indirect costs are limited to specific percentages based on funding source: eight percent for Independent Living Grant or state funds, fifteen percent for federal or other state funding under Modified Total Direct Costs methodology, or the agency's Federal Negotiated Indirect Cost Rate Agreement if applicable. Contractual and consultant services must include written agreements, method of selection (sole source or competitive bid), scope of work with specific deliverables, and accountability measures. The template includes a budget summary section reconciling all expense categories against funding sources and calculates the total program budget and indirect cost percentage. No specific response, due, or award dates are indicated in this template document, as it serves as a standardized application form for organizations to complete when applying for ADSD subaward funding.

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File Type Posted
ADSD Work Plan Template.docx DOCX document
ADSD FY2027 Competitive NOFO _ OMA.pdf PDF
ADSD Subaward Application - Competitive Form.docx DOCX document

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Budget Narrative Applicant Name: Type of Service: Please note: Most of this tab is not protected.

Be careful not to delete or overwrite formulas.

Type of Subaward (Fixed-Fee or Categorical), if known:
ADSD Subaward Application

PROPOSED BUDGET NARRATIVE

Personnel CostsFringe Only:$0.00Total:$0.00Expand row heights as necessary to show your entire response.
List staff, positions, salaries/rate of pay, fringe rate, percent of direct-service time to be spent on the project and the number of months to calculate the amount requested.
A.Position: Staff Name (if known, otherwise state new position), Title, Position Control Number (PCN)

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Include all of these items, as they are required per the NV Dept. of Health and Human Services (DHHS). If agency does not use PCN numbers, create a numbering system for position identification.Annual SalaryFringe Rate% of TimeMonthsFringe AmountAmount Requested
B.Provide a breakdown of the type of fringe benefits provided, such as health insurance, Medicare, FICA, worker's compensation, retirement, etc. -AND- Describe position duties as they relate to the funding and program objectives. Expand rows as needed.
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B.Unhide the additional rows if necessary
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B.
TravelTotal:$0.00*Revise this formula as needed to include each trip listed.
Identify staff who will travel, the purpose, frequency, and projected costs. Utilize GSA rates for per diem, lodging and mileage (www.gsa.gov) unless the organization's policies specify lower rates for these expenses. Out-of-state travel or non-standard fares require special justification. Any increases/decreases made to GSA.gov rates within the subaward period will be automatically honored during the reimbursement process.
Out-of-State TravelTrip total:$0.00*Revise this formula as needed to total each out-of-state trip separately.
Enter Title of Trip & Destination here, such as "CDC Conference: San Diego, CA"Cost# of Trips# of days# of Staff
Airfare: cost per trip (origin & designation) x # of trips x # of staff$0.00
Baggage fee: $ amount per person x # of trips x # of staff$0.00
Per Diem: $ per day per GSA rate for area x # of trips x # of staff$0.00
Lodging: $ per day + $ tax = total $ x # of trips x # of nights x # of staff$0.00
Ground Transportation: $ per r/trip x # of trips x # of staff$0.00
Mileage: (rate per mile x # of miles per r/trip) x # of trips x # of staff$0.00
Parking: $ per day x # of trips x # of days x # of staff$0.00
Justification: (Enter below, expand row as needed) Who will be traveling, when and why, tie into program objective(s) or indicate required by funder.

*If traveling to more than 1 out-of-state destination, copy section above and insert here.

In-State TravelTrip total:$0.00*Revise this formula as needed to total each in-state trip separately.
Enter Origin & Destination Here*Cost# of Trips# of days# of Staff
Airfare: cost per trip (origin & designation) x # of trips x # of staff$0.00
Baggage fee: $ amount per person x # of trips x # of staff$0.00
Per Diem: $ per day per GSA rate for area x # of trips x # of staff$0.00
Lodging: $ per day + $ tax = total $ x # of trips x # of nights x # of staff$0.00
Motor Pool:($ car/day + ## miles/day x $ rate per mile) x # trips x # days$0.00
Mileage (see below for general mileage): (rate per mile x # of miles per r/trip) x # of trips x # of staff$0.00
Parking: $ per day x # of trips x # of days x # of staff$0.00
Justification: (Enter below, expand row as needed) Who will be traveling, when and why, tie into program objective(s) or indicate required by funder.

*If traveling to more than 1 in-state destination, copy section above and insert here.

General/Other Mileage: Complete the following section for mileage expenses related to general program operation and not specific, planned trips. Enter the total general mileage expense in the Cost column. If more than one staff is traveling, provide a calculation for each staff member's mileage and the reason for travel.
General Mileage (rate per mile x # of miles):CostGeneral Mileage Total:$0.00
Calculation(s) and Reason(s):
If requesting funds for other types of travel related to program operations and not specific, planned trips, complete the following section.
Include justification for these expenses.Other Travel Total:$0.00
Enter Description(s) Below:Amount:
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Justification: (Enter below, expand row as needed) Who will be traveling, when and why, tie into program objective(s) or indicate required by funder.
OperatingTotal:$0.00
Include specific facility and vehicle costs associated with the proposed program (not the agency as a whole), such as rent, maintenance expenses, insurance, fuel, as well as utilities such as power, water and communications (phone/internet). Also list tangible and expendable personal property such as office supplies, program supplies, necessary software, postage, computers and related equipment which cost less than $10,000 per unit, etc. Provide a calculation for each line.
Enter Description(s) Below:Amount:
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Justification: (Enter below, expand row as needed) Provide narrative to justify purchase of meals, snacks, large expense or unusual budget items. Include details how budget item supports deliverables of the project.
EquipmentTotal:$0.00
List equipment to purchase or lease costing $10,000 or more (per unit), and justify these expenditures. Equipment costing less than $10,000 should be listed under Operating. Justify these items.
Enter Description(s) Below:Amount:
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ContractualTotal:$0.00*Revise this formula as needed to include all contractors listed.
Explain the need and/or purpose for the contractual or consultant service. Identify project workers who are not regular employees of the organization. Include costs of labor, travel, per diem, or other costs. Only include costs for which there is a written agreement or contract. Collaborative projects with multiple partners should expand this category to break out personnel, travel, equipment, etc., for each site. Sub-awards or mini-grants that are a component of a larger project or program may be included here, but require special justification as to the merits of the applicant serving as a "pass-through" entity, and its capacity to do so. Expand rows as needed.
Enter Name of Contractor, Subrecipient here:$0.00
Method of Selection:(explain here, i.e. sole source or competitive bid)
Period of Performance:
Scope of Work: (Define scope of work. What will be the specific services/tasks that will be completed and specific deliverables. How do deliverables relate to your goals and objectives, how will deliverables achieve your objective(s).)
Sole Source Justification: (Define if sole source method, not needed for competitive bid.)
Method of Accountability: (Define - Describe how the progress and performance of the consultant will be monitored. Identify who is responsible for supervising the consultant's work.)
Other Justification: (Other information that will help justify the use of this contractor.)
Cost Calculation: (Explain costs included in this contractor request.)
Unhide rows for additional Contractor sections if necessary.
Enter Name of Contractor, Subrecipient here:$0.00
Method of Selection:(explain here, i.e. sole source or competitive bid)
Period of Performance:
Scope of Work: (Define scope of work. What will be the specific services/tasks that will be completed and specific deliverables. How do deliverables relate to your goals and objectives, how will deliverables achieve your objective(s).)
Sole Source Justification: (Define if sole source method, not needed for competitive bid.)
Method of Accountability: (Define - Describe how the progress and performance of the consultant will be monitored. Identify who is responsible for supervising the consultant's work.)
Other Justification: (Other information that will help justify the use of this contractor.)
Cost Calculation: (Explain costs included in this contractor request.)
Enter Name of Contractor, Subrecipient here:$0.00
Method of Selection:(explain here, i.e. sole source or competitive bid)
Period of Performance:
Scope of Work: (Define scope of work. What will be the specific services/tasks that will be completed and specific deliverables. How do deliverables relate to your goals and objectives, how will deliverables achieve your objective(s).)
Sole Source Justification: (Define if sole source method, not needed for competitive bid.)
Method of Accountability: (Define - Describe how the progress and performance of the consultant will be monitored. Identify who is responsible for supervising the consultant's work.)
Other Justification: (Other information that will help justify the use of this contractor.)
Cost Calculation: (Explain costs included in this contractor request.)
Enter Name of Contractor, Subrecipient here:$0.00
Method of Selection:(explain here, i.e. sole source or competitive bid)
Period of Performance:
Scope of Work: (Define scope of work. What will be the specific services/tasks that will be completed and specific deliverables. How do deliverables relate to your goals and objectives, how will deliverables achieve your objective(s).)
Sole Source Justification: (Define if sole source method, not needed for competitive bid.)
Method of Accountability: (Define - Describe how the progress and performance of the consultant will be monitored. Identify who is responsible for supervising the consultant's work.)
Other Justification: (Other information that will help justify the use of this contractor.)
Cost Calculation: (Explain costs included in this contractor request.)
Enter Name of Contractor, Subrecipient here:$0.00
Method of Selection:(explain here, i.e. sole source or competitive bid)
Period of Performance:
Scope of Work: (Define scope of work. What will be the specific services/tasks that will be completed and specific deliverables. How do deliverables relate to your goals and objectives, how will deliverables achieve your objective(s).)
Sole Source Justification: (Define if sole source method, not needed for competitive bid.)
Method of Accountability: (Define - Describe how the progress and performance of the consultant will be monitored. Identify who is responsible for supervising the consultant's work.)
Other Justification: (Other information that will help justify the use of this contractor.)
Cost Calculation: (Explain costs included in this contractor request.)
Enter Name of Contractor, Subrecipient here:$0.00
Method of Selection:(explain here, i.e. sole source or competitive bid)
Period of Performance:
Scope of Work: (Define scope of work. What will be the specific services/tasks that will be completed and specific deliverables. How do deliverables relate to your goals and objectives, how will deliverables achieve your objective(s).)
Sole Source Justification: (Define if sole source method, not needed for competitive bid.)
Method of Accountability: (Define - Describe how the progress and performance of the consultant will be monitored. Identify who is responsible for supervising the consultant's work.)
Other Justification: (Other information that will help justify the use of this contractor.)
Cost Calculation: (Explain costs included in this contractor request.)
Enter Name of Contractor, Subrecipient here:$0.00
Method of Selection:(explain here, i.e. sole source or competitive bid)
Period of Performance:
Scope of Work: (Define scope of work. What will be the specific services/tasks that will be completed and specific deliverables. How do deliverables relate to your goals and objectives, how will deliverables achieve your objective(s).)
Sole Source Justification: (Define if sole source method, not needed for competitive bid.)
Method of Accountability: (Define - Describe how the progress and performance of the consultant will be monitored. Identify who is responsible for supervising the consultant's work.)
Other Justification: (Other information that will help justify the use of this contractor.)
Cost Calculation: (Explain costs included in this contractor request.)
Enter Name of Contractor, Subrecipient here:$0.00
Method of Selection:(explain here, i.e. sole source or competitive bid)
Period of Performance:
Scope of Work: (Define scope of work. What will be the specific services/tasks that will be completed and specific deliverables. How do deliverables relate to your goals and objectives, how will deliverables achieve your objective(s).)
Sole Source Justification: (Define if sole source method, not needed for competitive bid.)
Method of Accountability: (Define - Describe how the progress and performance of the consultant will be monitored. Identify who is responsible for supervising the consultant's work.)
Other Justification: (Other information that will help justify the use of this contractor.)
Cost Calculation: (Explain costs included in this contractor request.)
Enter Name of Contractor, Subrecipient here:$0.00
Method of Selection:(explain here, i.e. sole source or competitive bid)
Period of Performance:
Scope of Work: (Define scope of work. What will be the specific services/tasks that will be completed and specific deliverables. How do deliverables relate to your goals and objectives, how will deliverables achieve your objective(s).)
Sole Source Justification: (Define if sole source method, not needed for competitive bid.)
Method of Accountability: (Define - Describe how the progress and performance of the consultant will be monitored. Identify who is responsible for supervising the consultant's work.)
Other Justification: (Other information that will help justify the use of this contractor.)
Cost Calculation: (Explain costs included in this contractor request.)
Enter Name of Contractor, Subrecipient here:$0.00
Method of Selection:(explain here, i.e. sole source or competitive bid)
Period of Performance:
Scope of Work: (Define scope of work. What will be the specific services/tasks that will be completed and specific deliverables. How do deliverables relate to your goals and objectives, how will deliverables achieve your objective(s).)
Sole Source Justification: (Define if sole source method, not needed for competitive bid.)
Method of Accountability: (Define - Describe how the progress and performance of the consultant will be monitored. Identify who is responsible for supervising the consultant's work.)
Other Justification: (Other information that will help justify the use of this contractor.)
Cost Calculation: (Explain costs included in this contractor request.)
*If more Contractor/Consultant sections are needed, copy section above and insert here.
OtherTotal:$0.00
Identify and justify other direct expenditures that cannot be identified within another category, such as dues, other insurance, printing and promotional costs, etc. Requested funding must be for this specific proposed program. Include calculations for all items and a description if needed. If cost allocating an expense across multiple programs and sources, provide an explanation and calculation for the portion included here.
$0.00
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Justification: (Enter below, expand row as needed) Provide narrative to justify these expenditures and how each budget item supports the project.

TOTAL DIRECT PROJECT COSTS $0.00

Administrative Expenses/Indirect CostsTotal:$0.00*Enter total calculation based on type of federal rate selected. There is no formula in this cell.
Administrative expenses and FICR are to be used to help cover expenses that are not easily assignable to a specific program or unit within an organization. These costs are associated with depreciation and use allowances, facility operation and maintenance, general administrative expenses such as accounting, payroll, legal and data processing, and any personnel not providing direct services to the project. If requested, the expenses are limited to the maximum rate listed below, depending on the funding source and existence of an FICR percentage of the direct project costs requested from ADSD. Once a funding source is assigned to an approved subaward, the allowable rate will apply, and a budget revision may be required if excess expenses are included. Indirect/administrative expenses do not apply to fixed-fee subawards or portions of subawards. Indirect expenses must be applied using the agency's Federal Indirect Cost Rate (FICR) or Modified Total Direct Costs (MTDC) which excludes equipment, capital expenditures and items such as pass-through funds, and major subcontract(s) over the first $50,000, as applicable. Reference the Grant Instructions and Requirements for additional information on Indirect Costs.
Choose ONE type of rate according to funding source and provide calculation or explanations:RATE:
1.Independent Living Grant (ILG)/FHN State Funds and State Funds awarded to the NV System of Higher Education* (non-research): 8%
2.Federal/Other State Funding: 15% de minimis (Modified Total Direct Costs - MTDC)
3.Federal Negotiated Indirect Cost Rate Agreement (NICRA): Identify approved costs per the NICRA & attach the current agreement to application. In cells below, describe how the total indirect amount was calculated based on the NICRA letter guidance and exceptions. Expand row as needed.
FICR Calculation:
Other Explanations:

TOTAL BUDGET REQUEST $0.00

DHHS GIRS:https://dhhs.nv.gov/Programs/Grants/Links_to_GMU_Reports_and_Grantee_Documents/
Located under Grantee Forms and Other Documents

*State Memo on Allowable Indirect for the Nevada System of Higher Education (NSHE): 2017-12_Indirect_Cost_Rates_for_Grants_Contracts_NSHE.pdf

Include all of these items, as they are required per the NV Dept. of Health and Human Services (DHHS). If agency does not use PCN numbers, create a numbering system for position identification.

ADSD Subaward Application – Budget Template rev 5/10/2023 Page &P of &N https://dhhs.nv.gov/Programs/Grants/Links_to_GMU_Reports_and_Grantee_Documents/https://budget.nv.gov/uploadedFiles/budgetnvgov/content/Governance/Policy_Directives/2017/2017-12_Indirect_Cost_Rates_for_Grants_Contracts_NSHE.pdf Budget Summary

Applicant Name:Type of Service:
ADSD Subaward ApplicationPending
PROPOSED BUDGET SUMMARYSecured
Enter Info in Orange CellsN/A
A. FUNDING SOURCESADSD
FundsMATCH[Enter name of Other Funding, if applicable][Enter name of Other Funding, if applicable][Enter name of Other Funding, if applicable][Enter name of Other Funding, if applicable][Enter name of Other Funding, if applicable]TOTALFALSE
PENDING OR SECUREDPending
ENTER TOTAL FUNDING$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.00Check box if there is no match requirement per the NOFO, or at the direction of ADSD.
EXPENSE CATEGORY
Personnel$0.00$0.00
Travel$0.00$0.00
Operating$0.00$0.00
Equipment$0.00$0.00
Contractual/Consultant$0.00$0.00
Other Expenses$0.00$0.00
Indirect$0.00$0.00

TOTAL EXPENSE $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

These boxes should equal zero $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

Total Indirect Cost$0.00Total Program Budget$0.00
Indirect % of Budget0.00%ADSD Percent of Program BudgetERROR:#DIV/0!

B. Comments regarding budget summary, if applicable.

C. Identify specific source(s) of Match, as applicable, and indicate whether each source of match is Secured or Pending.

D. List potential amounts and sources of program income (required); and describe if the project plans to have a sliding fee scale or voluntary contributions.

ADSD Subaward Application – Budget Template rev. 5/10/2023

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