Attachment I Cost Proposal Form_NonBHS.xlsx

XLSX spreadsheet 210 KB Posted Aug 10, 2026

Attached to: DPH | Ending HIV Epidemic Intensive Case Mgmt
Solicitation number: SFGOV-0000011852
Issued by: San Francisco County, San Francisco City, California

About this file

Written by GovTribe AI · Aug 17, 2026

This file contains a cost proposal form and budget justification template issued by the San Francisco Department of Public Health (SFDPH) for a non-Behavioral Health Services contract related to an Ending HIV Epidemic Intensive Case Management program. The RFP was published on August 10, 2026, with a pre-proposal conference scheduled for August 17, 2026, a deadline for questions on August 24, 2026, and a proposal submission deadline of September 9, 2026. The estimated contract start date is March 1, 2027. The solicitation seeks proposals from qualified firms to operate an intensive case management program supporting people with HIV who face complex behavioral health issues and unstable housing that impede viral suppression, care engagement, and community stability. The contract documents include detailed instructions for budget preparation, fringe benefit rate calculations, and units of service (UOS) cost allocation by service mode, with provisions for multi-year contracts with multiple funding sources and programs.

The budget template demonstrates sample contract structures with expense categories including salaries, employee benefits, operating expenses, and indirect costs. The document specifies that contractors must complete fringe benefit rate forms identifying required versus discretionary benefits such as payroll taxes, workers' compensation, medical insurance, dental insurance, life insurance, vision insurance, pension plans, and 401(k) employer contributions. Contractors must indicate whether proposed rates apply to all staff funded through the DPH contract, confirm service level maintenance if direct service funding decreases, and disclose any staff unionization with associated negotiated fringe benefit rates. The template includes cost allocation procedures linking program narratives to budget justification pages, with distinct tabs for each funding source and fiscal year. Sample budget data shows contracts may include DPH funding sources such as HHS County General Fund, federal CARE Part A funding (CFDA #93.914), and state SAM funding (CFDA #93.917), with reimbursement methods designated as either Cost Reimbursement (CR) or Fee-For-Service (FFS).

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Other files

File	Type	Posted
Attachment D 12L Compliance.docx	DOCX document	Aug 10, 2026
Attachment F MCO Declaration Form.pdf	PDF	Aug 10, 2026
RFP_11852_EHE_ICM_Version_2.pdf	PDF	Aug 10, 2026
Attachment A Contact Information Cover Sheet.docx	DOCX document	Aug 10, 2026
Attachment G HCAO Declaration Form.pdf	PDF	Aug 10, 2026
DPH___Ending_HIV_Epidemic_Intensive_Case_Mgmt.xml	XML file	Aug 10, 2026
Attachment J HIV Referral - Acuity Scale.pdf	PDF	Aug 10, 2026
Attachment C Reference Form.docx	DOCX document	Aug 10, 2026
RFP_11852_EHE_ICM_8.10.26.pdf	PDF	Aug 10, 2026
RFP_11852_Addendum_No_1.pdf	PDF	Aug 10, 2026
DPH___Ending_HIV_Epidemic_Intensive_Case_Mgmt.pdf	PDF	Aug 10, 2026
Attachment E CMD LBE Form 2A_Professional Services.pdf	PDF	Aug 10, 2026
Attachment B Non-Collusion Affidavit Form.docx	DOCX document	Aug 10, 2026
Attachment H First Source.docx	DOCX document	Aug 10, 2026
RFP_Pre-Proposal_Conference_11852_EHE_ICM.pdf	PDF	Aug 10, 2026
Attachment M City's Contract Terms P-600 for Professional Services.pdf	PDF	Aug 10, 2026

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Fringe Rate Form Legal

	Contractor:
	Program(s):
	Effective Date:
1.	The fringe benefit rate is based on the most recent Financial Statement of the above program and is composed of the following benefits (please indicate which benefits are required and which are discretionary by placing an X in the appropriate column)
		▼Please Complete▼		Required	Discretionary
	Payroll tax FICA		%	XXX
	Payroll tax SUI		%	XXX
	Worker’s Compensation		%	XXX
	Medical Insurance		%	XXX
	Dental Insurance		%
	Life Insurance		%
	Vision Insurance		%
	Pension Plan		%
	401K Employer Contribution		%
	Other (please name if applicable)		%
	Total Fringe Benefits Percentage:	0	%

2.	Does the proposed rate apply to all staff funded through the DPH contract/MOU referenced above?	Yes	No
3.	Does this contractor/agency/program receive funding from another DPH Section?	Yes	No
	If yes, which DPH Section? (Mark all that apply.)	SOC Director Initial for Approval ▼
	Behavioral Health Services - Children, Youth, & Families (CYF)	£
	Behavioral Health Services - Adult and Older Adult (AOA)	£
	Maternal Child and Adolescent Health (MCAH)	£
	Primary Care - HIV Health Services (HHS)	£
	Community Health Equity & Promotion (CHEP)	£
	Community Health Equity & Promotion - HIV Prevention Services (HPS)	£
4.	Will the level of contract services be maintained, i.e. do you plan to serve the same number of clients, do you plan to provide the same amount of service if the direct service amount is decreased?	Yes	No
	If No, write brief explanation here and/or attach additional page.

5.	Will the hourly staff pay rate increase for the period in question?	Yes	No
6.	Is the applicable staff unionized?	Yes	No
	If yes, what is the negotiated fringe benefit rate for each class of employees? (attach additional page as necessary)

I affirm that the costs detailed above accurately reflect the benefits provided to employees of the program(s) designated above and are routine costs associated with the program(s).

Signature of Contractor/Provider	Date
For SFDPH Use Only
	Recommend for Appoval	Yes	No
	CDTA: Attach justification if approval is not recommended
	Please Indicate Rate Approved if Lower than Requested

Signature of CDTA Program Manager
Date Tracking Sheet Updated:	Date Loaded into COOL:
cc: COOL Quickflow to all appropriate parties

Fringe Rate Form Letter

	Contractor:
	Program(s):
	Effective Date:
1.	The fringe benefit rate is based on the most recent Financial Statement of the above program and is composed of the following benefits (please indicate which benefits are required and which are discretionary by placing an X in the appropriate column)
		▼Please Complete▼		Required	Discretionary
	Payroll tax FICA		%	XXX
	Payroll tax SUI		%	XXX
	Worker’s Compensation		%	XXX
	Medical Insurance		%	XXX
	Dental Insurance		%
	Life Insurance		%
	Vision Insurance		%
	Pension Plan		%
	401K Employer Contribution		%
	Other (please name if applicable)		%
	Total Fringe Benefits Percentage:	0	%
2.	Does the proposed rate apply to all staff funded through the DPH contract/MOU referenced above?			Yes	No
3.	Does this contractor/agency/program receive funding from another DPH Section?			Yes	No
	If yes, which DPH Section? (Mark all that apply.)			SOC Director Initial for Approval ▼
	Behavioral Health Services - Children, Youth, & Families (CYF)			£
	Behavioral Health Services - Adult and Older Adult (AOA)			£
	Maternal Child and Adolescent Health (MCAH)			£
	Primary Care - HIV Health Services (HHS)			£
	Community Health Equity & Promotion (CHEP)			£
	Community Health Equity & Promotion - HIV Prevention Services (HPS)			£
4.	Will the level of contract services be maintained, i.e. do you plan to serve the same number of clients, do you plan to provide the same amount of service if the direct service amount is decreased?			Yes	No
	If No, write brief explanation here and/or attach additional page.

5.	Will the hourly staff pay rate increase for the period in question?	Yes	No
6.	Is the applicable staff unionized?	Yes	No
	If yes, what is the negotiated fringe benefit rate for each class of employees? (attach additional page as necessary)

I affirm that the costs detailed above accurately reflect the benefits provided to employees of the program(s) designated above and are routine costs associated with the program(s).

Signature of Contractor/Provider	Date
For SFDPH Use Only
	Recommend for Appoval (CDTA: Attach justification if approval is not recommended)	Yes	No
	Please Indicate Rate Approved if Lower than Requested

Signature of CDTA Program Manager
Date Tracking Sheet Updated:	Date Loaded into COOL:
cc: COOL Quickflow to all appropriate parties

Before you Begin Instructions Preparing contract documents using the non-BHS Appendix B: NOTE: Many cells in this Summary Page link to UOS Cost Allocation and Budget Justification pages. Budget modeling and preparation should begin on the Budget Justification pages as budget calculations performed there will link to and prepopulate cells on the UOS Cost Allocation and Budget Summary Pages.

Each non-BHS Appendix B is to contain a Budget Summary that summarizes all funding sources and/or programs contained in the budget. For every fiscal year:

· each program narrative (A-1, A-2, etc.) is to have a corresponding UOS Cost Allocation and Budget Justification. A-1 will have a corresponding B-1; A-2 will have a corresponding B-2, etc.

· each funding source is to have a UOS Cost Allocation tab and corresponding Budget Justification tab distinguished by a lower-case letter (B-1a, B-1b, B-2a, B-2b, etc.) if more than one funding source exists.

· each fiscal year in a multi-year contract is also distinguished by a lower case letter following the funding source/program budget number if more than one fiscal year is included.

For each program and/or funding source, a program narrative (Appendix A-x) is to accompany the corresponding UOS Cost Allocation tab in the Appendix B. Unlike the tabs in the Appendix B, an Appendix A-x for each program and/or funding source may contain multiple fiscal years and each fiscal year is to be clearly identified in the Service Modes UOS Description Table(s).

NOTE: This workbook is structured with 2 Budget Summary Pages to accommodate up to 12 pairs of UOS Cost Allocation and Budget Justification pages.

If your budget document is using ONLY ONE Budget Summary Page, Hide Budget Summary Page (2) and all other unused Tabs in the Appendix B workbook.

YOU MUST HIDE ANY UNUSED tabs in the Appendix B Workbook. DO NOT DELETE unused tabs OR columns.

If your budget document requires the SECOND Budget Summary Page, then change Column H to "Sub-Totals".

These sub-total amounts are already linked to Summary Page (2).

For instructional purposes some of the cells in this workbook have been left partially filled out to demonstrate how some of the cells are set to create formulas, and

and to demonstrate linkages between document pages/ tabs.

Below is an example of the contract documents and tab numbering for a three-year multiyear contract with 1 program and 2 different funding sources (Grant and General Fund):

For Contracts with Multiple Years of Fundings, Multiple Funding Source, and/or Multiple Programs pagination can become complicated.

Please contact your CDTA Program Manager to discuss proper pagination sequencing when required.

A-1 Program Narrative Grant Funded (create separate UOS tables)

A-2 Program Narrative General Fund

NEW: UOS & UDC Allocation Page

This UOS calculations table has been moved from the Narrative Pages in the Contract to the Budget Workbook and will become part of the official contract documents as an Attachment to the Budget..

Moving the UOS and UDC details in this table to become an attachment to the budget, will allow details here to be edited as part of the RPB (Revision to Program Budget) process while only submitting budget documents, and contract narratives will no longer be submitted as part of the RPB process.

This will expedite the process and eliminate potential changes to the Scope of Work during the RPB process. If changes are made to the Scope of Work, it could require an Amendment.

Additionally, the Contract Summary Page has been eliminated from new Non-BHS contract documents as well, with the UOS and UDC information over the course of multi-year funding and multiple funding sources now represented here in the UOS & UDC Allocation Page attachment.

A Sample of a UOS & UDC Allocation Page is on the next tab, which will need to be edited and reformatted to capture the details required.

App B Budget Summary (contains all 3 fiscal years; funding sources are distinguished by column)

Fiscal Year 1: App B-1, Pg 1 (Grant Funded UOS Cost Allocation tab)

App B-1 BudJust (Grant Fund Budget Justification tab)

App B-2, Pg 1 (General Fund UOS Cost Allocation tab)

App B-2 BudJust (General Fund Budget Justification tab)

Fiscal Year 2: App B-1a, Pg 1 (Grant Funded UOS Cost Allocation tab)

App B-1a BudJust (Grant Funded Budget Justification tab)

App B-2a, Pg 1 (General Fund UOS Cost Allocation tab)

App B-2a BudJust (General Fund Budget Justification tab)

Fiscal Year 3: App B-1b, Pg 1 (Grant Funded UOS Cost Allocation tab)

App B-1b BudJust (Grant Funded Budget Justification tab)

App B-2b, Pg 1 (General Fund UOS Cost Allocation tab)

App B-2b BudJust (General Fund Budget Justification tab)

NOTE: The order or sequence of tabs within the Budget Workbook should be organized by Fiscal Year. With all program and funding source tabs organized by year. In the example above the tabs would be organized from left to right in this order.

NON-BHS APPENDIX B - General Instructions

NEW UOS&UDC Allocations

Contractor / Provider	Provider Name here
Total Contract / Term	$X,XXX,XXX (Full Amount of Contract)	Term of Full Contract
Address / Phone
Contact Person
System of Care / RFP #			RFP # xx-20xx

Program Name
Funding Source	Name of Funding Source
Appendices	A-1 / B-1			A-1 / B-2			A-1 /B-3
Amount	Appendix Amount			Appendix Amount			Appendix Amount
Term	Appendix Term			Appendix Term			Appendix Term
	Sample provided below:	UOS	UDC		UOS	UDC		UOS	UDC
	Professional Patient Days (RN, SW, LVN Care)			Name of Service Modality	x,xxx	xx	Name of Service Modality	x,xxx	xx
UOS target determined by formula	9 Beds x 365 days x 80% Average Occupancy	2,333	22	UOS formula calculation			UOS formula calculation
	Name of Service Modality			Name of Service Modality	x,xxx	xx	Name of Service Modality	x,xxx	xx
	UOS formula calculation	x,xxx	xx	UOS formula calculation			UOS formula calculation

A-1 / B-4			A-1 / B-4a.1			A-1 /B-5
Appendix Amount			Appendix Amount			Appendix Amount
Appendix Term			Appendix Term			Appendix Term
Name of Service Modality	x,xxx	xx	Name of Service Modality	x,xxx	xx	Name of Service Modality	x,xxx	xx
UOS formula calculation			UOS formula calculation			UOS formula calculation
Name of Service Modality	x,xxx	xx	Name of Service Modality	x,xxx	xx	Name of Service Modality	x,xxx	xx
UOS formula calculation			UOS formula calculation			UOS formula calculation

Funding Source	RWPA
Appendices	A-1 / B-6			A-1 / B-7
Amount	Appendix Amount			Appendix Amount
Term	Appendix Term			Appendix Term
		UOS	UDC		UOS	UDC
	Name of Service Modality	x,xxx	xx	Name of Service Modality	x,xxx	xx
	UOS formula calculation			UOS formula calculation
	Name of Service Modality	x,xxx	xx	Name of Service Modality	x,xxx	xx
	UOS formula calculation			UOS formula calculation

Funding Source	RWPB		RWPB - X08		RWPB
Appendices	A-1 / B-1a		A-1 / B-1a.1		A-1 / B-2a
Amount	$294,124		$157,825		$392,166
Term	7/1/17- 3/31/18		9/30/17-9/29/18		4/1/18-3/31/19
Definition of UOS :	UOS	UDC	UOS	UDC	UOS	UDC
Professional Pt Days	778	2	N/A	N/A	1,168	14
ParaProfess Pt Days	778	2	N/A	N/A	1,168	14
Facility Expenses Months	N/A	N/A	12	N/A	N/A	N/A
Totals	1,556	2	12	N/A	2,336	14

Funding Source	RWPB		RWPB		RWPB
Appendices	A-1 / B-5a		A-1 / B-6a		A-1 / B-7a
Amount	$586,216		$657,053		$657,053
Term	4/1/21-3/31/22		4/1/22 -3/31/23		4/1/23-3/31/24
Definition of UOS :	UOS	UDC	UOS	UDC	UOS	UDC
Professional Pt Days	1,706	17	1,939	20	1,939	20
ParaProfess Pt Days	1,706	17	1,939	20	1,939	20
Facility Expenses Months	N/A	N/A	N/A	N/A	N/A	N/A
Totals	3,412	17	3,878	20	3,878	20

*****Total UDC is not the sum of UDC from each mode of service

Contractor / Provider Maitri AIDS Hospice (continued)

Program Name	Maitri Compassionate Care HIV / Mental Health Program
Funding Source	RWPB - X08		RWPB - X07		RWPB
Appendices	A-2 / B-1b		A-2 / B-2b		A-2 / B-2c
Amount	$95,000		$133,803		$95,000
Term	9/30/17- 9/29/18		4/1/18-3/31/19		4/1/19-3/31/20
Definition of UOS:	UOS	UDC	UOS	UDC	UOS	UDC
Interns Mental Hlth Indiv Hrs	528	10	936	10	N/A	N /A
Interns Mental Hlth Group Hrs	82	10	104	10	N/A	N /A
LCSW Mental Health Individual Hrs	N/A	N /A	156	10	234	10
LCSW Mental Hlth Group Therapy Hrs	N/A	N /A	17	10	18	10
RN Psychoeducation Grp Hrs	N/A	N /A	20	10	N/A	N /A
Start Up Months	N/A	N /A	5	N/A	N/A	N /A
Volunteer Mental Health Group Hrs	N/A	N /A	N/A	N/A	182	10
Mental Health Aftercare Individual Hrs	N/A	N/A	N/A	N/A	N/A	N/A
Mental Hlth Aftercare Group Therapy Hrs	N/A	N/A	N/A	N/A	N/A	N/A
Administrative Mngt Months (MCO)	N/A	N /A	N/A	N/A	N/A	N/A
Totals	610	10	1,238	10	434	10

Program Name	Maitri Compassionate Care HIV / Mental Health Program
Funding Source	RWPB		RWPB
Appendices	A-2 / B-2f		A-2 / B-2g
Amount	$95,000		$95,000
Term	4/1/22-3/31/23		4/1/23-3/31/24
Definition of UOS:	UOS	UDC	UOS	UDC	UOS	UDC
Interns Mental Hlth Indiv Hrs	N/A	N /A	N/A	N /A
Interns Mental Hlth Group Hrs	N/A	N /A	N/A	N /A
LCSW Mental Health Individual Hrs	528	16	528	16
LCSW Mental Hlth Group Therapy Hrs	240	16	240	16
RN Psychoeducation Grp Hrs	N/A	N /A	N/A	N /A
Start Up Months	N/A	N /A	N/A	N /A
Volunteer Mental Health Group Hrs	N/A	N /A	N/A	N /A
Mental Health Aftercare Individual Hrs	96	8	96	8
Mental Hlth Aftercare Group Therapy Hrs	144	12	144	12
Administrative Mngt Months (MCO)	N/A	N/A	N/A	N /A
Totals	1,008	16	1,008	16

*****Total UDC is not the sum of UDC from each mode of service

Target Population	Maitri will serve all ethnicities and populations within San Francisco, with focused expertise to meet the unique needs of the priority population who are people with HIV/AIDS and in need of hospice or 24-hour skilled nursing care.
Description of Services	Professional / Paraprofessional Pt Days: RN, LVN, Social Work, and CNA Services within a licensed Residential Care Facility for the Chronically Ill (RCFCI).

Mental Health Services: psychosocial assessments, development of care plans, client-tailored interventions including counseling; individual and group mental health services provided by the staff Volunteer Coordinator, interns, an LCSW, an ACSW, and an RN.

Mental Health Individual Hours: comprehensive evaluations, short-term and ongoing therapeutic interventions

Mental Health Group Hours: psychosocial support groups focusing on stress management and encouraging self-care, mutual self-help to encourage development of coping skills

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&"Arial Narrow,Bold"Attachment 1 00/00/0000 - 00/00/0000 Funding Source

&"Times New Roman,Regular"&10Attachment 1 Revision: 00/00/0000 &"Times New Roman,Regular"&10 1 of 1 &"Times New Roman,Regular"&10Contract ID# 10000xxxxx

Budget Summary by Program

DPH 1: Department of Public Health Contract Budget Summary by Program								NOTE: Many cells in this Summary Page link to UOS Cost Allocation and Budget Justification pages.
CID #:							Appendix B	Budget modeling and preparation should begin on the Budget Justification pages as budget calculations performed there will link to and prepopulate cells on the UOS Cost Allocation and Budget Summary Pages.
DPH Section:					Contract Term :			Contract term is often multi-year and the start date is the first day of the earliest term funded, end date is the last day of latest term funded.
Check one: [ ] Original Agreement [ ] Amendment [ ] Revision to Program Budgets						Current Funding Notification Date:		Date format must be mm/dd/yy
Agency/Contractor Name:	ABC CBO
Program/Provider Name:	Ending the HIV Epidemic Intensive Case Management	ERROR:#REF!	ERROR:#REF!	ERROR:#REF!	ERROR:#REF!	ERROR:#REF!	TOTALS
Appendix Number:	A-1/B-1	A-2/B-2	A-1/B-1a	A-2/B-2a	A-2/B-1b	A-2/B-2b
Appendix Term:	03/01/27 - 02/28/28	07/01/19 - 06/30/20	03/01/20 - 02/28/21	07/01/20 - 06/30/21	03/01/21 - 02/28/22	07/01/21 - 06/30/22		Date format must be mm/dd/yy.
EXPENSES
Salaries	$ 40,000	ERROR:#REF!	ERROR:#REF!	ERROR:#REF!	ERROR:#REF!	ERROR:#REF!	ERROR:#REF!	When representing additional NON-DPH Funding Sources in Rows 34 - 36 below, you will need to enter
Employee Benefits	$ 11,960	ERROR:#REF!	ERROR:#REF!	ERROR:#REF!	ERROR:#REF!	ERROR:#REF!	ERROR:#REF!	the additional amount in the appropriate expense row as well.
Total Personnel Expenses	$ 51,960	ERROR:#REF!	ERROR:#REF!	ERROR:#REF!	ERROR:#REF!	ERROR:#REF!	ERROR:#REF!	Click within the appropriate Expense cells in columns B through G and then after the existing formula hard type
Employee Fringe Benefit Rate	29.9%	ERROR:#REF!	ERROR:#REF!	ERROR:#REF!	ERROR:#REF!	ERROR:#REF!	ERROR:#REF!	the additional funding amount as required.
Operating Expense	$ 11,340	ERROR:#REF!	ERROR:#REF!	ERROR:#REF!	ERROR:#REF!	ERROR:#REF!	ERROR:#REF!
Capital Expense ($5,000 and over)	$ -	$ -	$ -	$ -	$ -	$ -	$ -
Subtotal Direct Costs	$ 63,300	ERROR:#REF!	ERROR:#REF!	ERROR:#REF!	ERROR:#REF!	ERROR:#REF!	ERROR:#REF!
Indirect Cost Amount	$ 5,697	ERROR:#REF!	ERROR:#REF!	ERROR:#REF!	ERROR:#REF!	ERROR:#REF!	ERROR:#REF!
Indirect Cost Rate (%)	9.0%	ERROR:#REF!	ERROR:#REF!	ERROR:#REF!	ERROR:#REF!	ERROR:#REF!	ERROR:#REF!
Total Expenses	$ 68,997	ERROR:#REF!	ERROR:#REF!	ERROR:#REF!	ERROR:#REF!	ERROR:#REF!	ERROR:#REF!
REVENUES & FUNDING SOURCES
DPH Funding Sources (select from drop-down list)
HHS COUNTY GF							-
HHS FED CARE Part A - PD13, CFDA #93.914							-
HHS STATE SAM - HCAO16, CFDA #93.917							-
							-	Please hide unused rows to minimize document size.
							-
							-
							-
							-
							-
This row left blank for funding sources not in drop-down list							-
Total DPH Revenues	$ -	$ -	$ -	$ -	$ -	$ -	-
Non-DPH Funding Sources (select from drop-down list)
							- 0
							- 0
							- 0
This row left blank for funding sources not in drop-down list							- 0
Total Non-DPH Revenues	$ -	$ -	$ -	$ -	$ -	$ -	$ -
Total Revenues (DPH and Non-DPH)	$ -	$ -	$ -	$ -	$ -	$ -	$ -
Cost Reimbursement (CR) or Fee-For-Service (FFS)	(CR)	(CR)	(CR)	(CR)	(CR)	(CR)		Please be sure to select type of reimbursement method (CR vs. FFS) from drop down list.
Prepared By			Phone #					FFS means program invoices DPH based on number of UOS provided each mo. X cost per UOS in contract

CR means program invoices DPH based on line item amounts of final approved budget; program costs are reimbursed based upon actual costs of program details in budget.

							HHS contractors requesting FFS payment must obtain prior authorization from HHS; FFS requires annual cost reconciliation from contractor; potential repayment if actual costs are lower than projected.
CHECK: FUNDING USES = FUNDING SOURCES (Should always be 0)	68,997	ERROR:#REF!	ERROR:#REF!	ERROR:#REF!	ERROR:#REF!	ERROR:#REF!	Total Expenditures MUST equal total revenue. Values in these cells should = 0.

Page &P

Budget Summary w Capital

DPH 1: Department of Public Health Contract Budget Summary by Program
CMS 4555							Page #	Appendix B
DPH Section							Contract Term (mm/dd/yyyy)
Check one: [ ] Original [ ] Amendment [ ] Internal Contract Revision							Fiscal Year(s)
Agency/Contractor Name							Funding Notification Date
Contractor Name (may be same as above)
Program/Provider Name								TOTALS
Appendix Number	A-1/B-1	A-2/B-2	A-3/B-3	A-4/B-4	A-5/B-5	A-6/B-6	A-7/B-7
Appendix Term (mm/dd/yy-mm/dd/yy)
EXPENSES
Salaries	$ 40,000	$ -	$ -	$ -	$ -	$ -	$ -	$ 40,000
Employee Benefits	$ 11,960	$ -	$ -	$ -	$ -	$ -	$ -	$ 11,960
Total Personnel Expenses	$ 51,960	$ -	$ -	$ -	$ -	$ -	$ -	$ 51,960
Employee Fringe Benefit Rate	29.9%	0.0%	0.0%	0.0%	0.0%	0.0%	0.0%	29.9%
Operating Expense	$ 50,000	$ -	$ -	$ -	$ -	$ -	$ -	$ 50,000
Capital Expense ($5,000 and over)	$ 65,000	$ -	$ -	$ -	$ -	$ -	$ -	$ 65,000
Subtotal Direct Costs	$ 166,960	$ -	$ -	$ -	$ -	$ -	$ -	$ 166,960
Indirect Cost Amount	$ 86,666	$ -	$ -	$ -	$ -	$ -	$ -	$ 86,666
Indirect Cost Rate (%)	85.0%	0.0%	0.0%	0.0%	0.0%	0.0%	0.0%	85.0%
Total Expenses	$ 253,626	$ -	$ -	$ -	$ -	$ -	$ -	$ 253,626
REVENUES & FUNDING SOURCES
DPH Funding Sources (select from drop-down list)
HHS COUNTY GF								- 0
HHS FED CARE Part A - PD13, CFDA #93.914								- 0
HHS STATE SAM - HCAO16, CFDA #93.917								- 0
								- 0
								- 0
								- 0
								- 0
								- 0
								- 0
This row left blank for funding sources not in drop-down list								- 0
Total DPH Revenues	- 0	- 0	- 0	- 0	- 0	- 0	- 0	- 0
Non-DPH Funding Sources (select from drop-down list)
								- 0
								- 0
								- 0
This row left blank for funding sources not in drop-down list								- 0
Total Non-DPH Revenues	- 0	- 0	- 0	- 0	- 0	- 0	- 0	- 0
Total Revenues (DPH and Non-DPH)	- 0	- 0	- 0	- 0	- 0	- 0	- 0	- 0
Payment Method
Prepared By			Phone #

CHECK: FUNDING USES = FUNDING SOURCES (Should always be 0) 253,626 0 0 0 0 0 0

Agreement/Amendment: date (mm/dd/yyyy)

App B-1 w Capital Page 1

Contractor Name		Appendix #
Contract Term (mm/dd/yyyy)		Page #
Funding Source		Fiscal Year(s)
		Funding Notification Date
	UOS COST ALLOCATION BY SERVICE MODE

		SERVICE MODES
Personnel Expenses								Contract Totals
Position Titles	Annualized FTE	Salaries	% FTE	Salaries	% FTE	Salaries	% FTE		Category Totals From Bgt Justification
Medical Case Manager	0.67	40,000	100%		0%		0%	40,000	$ 40,000	Note: Links provided to default Budget Justification. If rows or columns have been added or deleted, check links to update
0	- 0	-	0%	-	0%	-	0%	-	$ - 0

0	- 0	-	0%	-	0%	-	0%	-	$ - 0
0	- 0	-	0%	-	0%	-	0%	-	$ - 0
0	- 0		0%	-	0%	-	0%	-	$ - 0
0	- 0	-	0%	-	0%	-	0%	-	$ - 0
Total Annualized FTE & Salaries	0.67	40,000	100%	-	0%	-	0%	40,000	$ 40,000
Fringe Benefits	29.9%	11,960	100%	-	0%	-	0%	11,960	$ 11,960
Total Personnel Expenses		51,960	100%	-	0%	-	0%	51,960	$ 51,960

Operating Expenses	Expenditure	%	Expenditure	%	Expenditure	%	Contract Total		Note: These should be the same operating expense categories that show up on the invoice template
Total Occupancy	-	0%	-	0%	-	0%	-	$ 11,340
Total Materials and Supplies	-	0%	-	0%	-	0%	-	$ - 0
Total General Operating	-	0%	-	0%	-	0%	-	$ - 0
Total Staff Travel	-	0%	-	0%	-	0%	-	$ - 0
Consultants/Subcontractor:	-	0%	-	0%	-	0%	-	$ - 0
Other (specify):	-	0%	-	0%	-	0%	-	$ - 0
Consultants/Subcontractor:	50,000	100%		0%		0%	50,000
		0%		0%		0%	-
		0%		0%		0%	-
		0%		0%		0%	-
		0%		0%		0%
Total Operating Expenses	50,000	100%	-	0%	-	0%	50,000	$ 11,340

Capital Expenses	Expenditure	%	Expenditure	%	Expenditure	%	Contract Total
New Van	65,000	100%	-	0%	-	0%	65,000	ERROR:#REF!
Capital Expenditure 2		0%		0%		0%	-	ERROR:#REF!
Total Capital Expenses	65,000	100%	-	0%	-	0%	65,000	ERROR:#REF!

Total Direct Expenses		166,960	100%	-	0%	-	0%	166,960	$ 63,300
Indirect Expenses	85.0%	86,666	100%		0%		0%	86,666	$ 5,697	9%
TOTAL EXPENSES		253,626	100%	-	0%	-	0%	253,626	$ 68,997

Units of Service (UOS) per Service Mode	-	-	-	-
Cost Per Unit of Service by Service Mode	ERROR:#DIV/0!	- 0	- 0
Unduplicated Clients (UDC) per Service Mode

Rev. 07/15 cost Cap for this service Over (under): Can this informaiton be on a drop-down list?

B-1 BgtJustf w Capital

BUDGET JUSTIFICATION

Contractor Name	0	Appendix #:
Program Name:	0	Fiscal Year:	12/31/99
1a) SALARIES

Staff Position 1:	Case Manager	Example Staff Position 1:	Program Director
Brief description of job duties:		Example Brief description of job duties:	Provides primary medical care to program clients including an initial risk assessment, history and physical, ordering pertinent labs. Requires working with a multidisciplinary team to assess patients on an ongoing
Minimum qualifications:		Example Minimum qualifications:	MD license, 15 hours of HIV-related CME annually, and the direct care of at least 20 HIV positive patients annually, 5 years experience.

Annual Salary:	x FTE:	x Months per Year:	Annualized (if less than 12 months):	Total	Example Annual Salary:	x FTE:	x Months per Year:	Annualized (if less than 12 months):	Total
$100,000.00	1.00	12	1.000	$ 100,000	$200,000.00	1.00	8	0.67	$133,333

Staff Position 2:

Brief description of job duties:

Minimum qualifications:

Annual Salary:	x FTE:	x Months per Year:	Annualized (if less than 12 months):	Total
			0.000	$ -

Staff Position 3:

Brief description of job duties:

Minimum qualifications:

Annual Salary:	x FTE:	x Months per Year:	Annualized (if less than 12 months):	Total
			0.0000	$ -

Staff Position 4:

Brief description of job duties:

Minimum qualifications:

Annual Salary:	x FTE:	x Months per Year:	Annualized (if less than 12 months):	Total
			0.0000	$ -

Staff Position 5:

Brief description of job duties:

Minimum qualifications:

Annual Salary:	x FTE:	x Months per Year:	Annualized (if less than 12 months):	Total
			0.0000	$ -

Staff Position 6:	Dean's Massage Therapist
Briefly describe the client service activities contributed by this position specifically for this program
Minimum qualifications/education/licensure:

Annual Salary:	Base FTE	x Months per Year:	Annualized FTE	Total
$100,000.00	1.00	4.0	0.3333	$ 33,333	How is this narrative formula written?

	Base Total FTE:	2.00		Total Salaries:	$ 133,333
			Annualized FTE	1.33
1b) EMPLOYEE FRINGE BENEFITS:
(Components provided below are samples only. The budgeted components should reflect the contractor's ledger accounts.)
Component				Cost			Prepopulate with percentages
Social Security				$ 10,200		7.65%	<== Changing these percentages will automatically update the amounts in Fringe Benefits
Retirement				$ 1,800		1.35%
Medical				$ 13,067		9.80%
Dental				$ - 0		0.00%
Unemployment Insurance				$ 2,933		2.20%
Disability Insurance				$ - 0		0.00%
Paid Time Off				$ - 0		0.00%
Other (specify):				$ - 0		0.00%
				Total Fringe Benefit:	28,000

Fringe Benefit %: 21.00%

TOTAL SALARIES & EMPLOYEE FRINGE BENEFITS: 161,333

2) OPERATING EXPENSES:

Occupancy:

Expense Item	Brief Description	Rate	Cost	Expense Item	Brief Description	Rate	Cost
				Example: Rent	Rental of program clinic space at 1234 A Street	$3000/month	36,000

	Total Occupancy:	- 0
Materials & Supplies:

Expense Item	Brief Description	Rate	Cost	Expense Item	Brief Description	Rate	Cost
				Example: Office Supplies	Pens, paper, print cartridges	$200/month	2,400

Total Materials & Supplies: - 0

General Operating:

Expense Item	Brief Description	Rate	Cost	Expense Item	Brief Description	Rate	Cost
				Example: Training/Staff Development	Annual CPR/First Aid certification	$100/person	1,200

	Total General Operating:	- 0
Staff Travel:

Purpose of Travel	Location	Expense Item	Rate	Cost	Purpose of Travel	Location	Expense Item	Rate	Cost
					Example: Grantee Conference	Washington, D.C.	Airfare	$200/flight x 2 persons	400

	Total Staff Travel:	- 0
Consultants/Subcontractors:

Consultant/Subcontractor Name	Service Description	Rate	Cost	Consultant/Subcontractor Name	Service Description	Rate	Cost
				Example: Trainers Inc.	Conduct Health Education trainings at area schools 4 times per year	$500/training	2,000

	Total Consultants/Subcontractors:	- 0
Other:

Expense Item	Brief Description	Rate	Cost	Expense Item	Brief Description	Rate	Cost
				Example: Client Stipends	Gift cards to encourage client participation	$50/card x 20 cards	1,000

Total Other: - 0

		TOTAL OPERATING EXPENSES:	- 0
3) CAPITAL EXPENDITURES: (If needed. A unit valued at $5,000 or more)
Capital Expenditure Item	Brief Description		Cost

TOTAL CAPITAL EXPENDITURES: - 0

	TOTAL DIRECT COSTS:	161,333
4) INDIRECT COSTS

Describe method and basis for Indirect Cost Allocation (i.e., FTE, square footage, or other) Amount

Indirect Rate:	15%
TOTAL INDIRECT COSTS:	- 0

TOTAL EXPENSES: 161,333

Capital Expenditure Item	Brief Description	Cost
Example: Kitchen Remodel	Upgrade of kitchen area to expand vocational training program	15,000

UOS Cost Alloc. B-1 Pg 1

Contractor:	ABC CBO		Appendix:	B-1
Program:	Ending the HIV Epidemic Intensive Case Management		Appendix Term:		Prepare Budget Justification FIRST! The totals from these columns LINK to the UOS Cost Allocation Page.
Full Contract Term:			Funding Source:	See Fund Notice	Full Contract Term is for the full term of your multi-year program, for all funding sources. Appendix Term is Specific to Funding Source and Term indicated in the Funding Notice
		UOS COST ALLOCATION BY SERVICE MODE			If more than 4 mode of service columns are needed, highlight Column I and J, copy, and paste/insert new columns, adjusting page/column width as needed to make it fit on one page.

Service Modes: Something Else Non-HHS Non-Medical Case Management Treatment Adherence Peer Advocacy If HHS funded, utilize pull down menu to select service mode; Cost Caps will populate in Row 47, with Rows 49 thru 53 demonstrating $ over/under cap.

If not HHS funded, type in your Service Mode, click "OK" when dialog box appears and then in Row 39, type in correct Service Type.

Position Titles	Annualized FTE	Salaries	% FTE	Salaries	% FTE	Salaries	% FTE	Salaries	% FTE	Totals	Category Totals From Bgt Justification details link here in Column L
Medical Case Manager	0.67		0%	40,000	100%	-	0%		0%	40,000	$ 40,000	Note: Values in Column L are linked to totals in Budget Just .
0	0.00		0%		0%		0%		0%	-	$ - 0	Adjust $$ in service mode columns (Positions & Operating Expenses) as needed to reflect service modality costs and adjust UOS rates
0	0.00		0%		0%		0%		0%	-	$ - 0	This can help you to adjust UOS rates, to meet program requirements or cost caps
0	0.00		0%		0%		0%		0%	-	$ - 0	Totals in Column K MUST equal total in Column L.
0	0.00		0%		0%		0%		0%	-	$ - 0
0	0.00		0%		0%		0%		0%	-	$ - 0	HIDE UNUSED ROWS AND COLUMNS
0	0.00		0%		0%		0%		0%	-	$ - 0
0	0.00		0%		0%		0%		0%	-	$ - 0
0	0.00		0%		0%		0%		0%	-	$ - 0
0	0.00		0%		0%		0%		0%	-	$ - 0
Total FTE & Salaries	0.67	-	0%	40,000	100%	-	0%	-	0%	40,000	$ 40,000
Fringe Benefits	29.90%	-	0%	11,960	100%	-	0%	-	0%	11,960	$ 11,960
Total Personnel Expenses		-	0%	51,960	100%	-	0%	-	0%	51,960	$ 51,960
											Insert additional rows as necessary for salaries and operating expenses
Operating Expenses		Expense	%	Expense	%	Expense	%	Expense	%	Totals	Note: These should be the same operating expense categories that show up on the invoice template
Total Occupancy		2,835	25%	2,835	25%	2,835	25%	2,835	25%	11,340	$ 11,340
Total Materials and Supplies			0%		0%		0%		0%	-	$ - 0
Total General Operating			0%		0%		0%		0%	-	$ - 0
Total Staff Travel			0%		0%		0%		0%	-	$ - 0
Consultants/Subcontractor:
0			0%		0%		0%		0%	-	$ - 0
0			0%		0%		0%		0%	-	$ - 0
0			0%		0%		0%		0%	-	$ - 0
0			0%		0%		0%		0%	-	$ - 0
Other (specify):
0			0%		0%		0%		0%	-	$ - 0
0			0%		0%		0%		0%	-	$ - 0
Total Operating Expenses		2,835	25%	2,835	25%	2,835	25%	2,835	25%	11,340	$ 11,340

Total Direct Expenses		2,835	4%	54,795	87%	2,835	4%	2,835	4%	63,300	$ 63,300
Indirect Expenses	9.0%	255	4%	4,932	87%	255	4%	255	4%	5,697	$ 5,697	9.0%
TOTAL EXPENSES		3,090	4%	59,727	87%	3,090	4%	3,090	4%	68,997	$ 68,997

Unit of Service Type	ERROR:#N/A	Hour	Hour	Hour
Number of UOS per Service Mode		832			832
Cost Per UOS by Service Mode	ERROR:#DIV/0!	$71.79	ERROR:#DIV/0!	ERROR:#DIV/0!	N/A
Number of UDC/NOC per Service Mode						In Row 40, Column K DO NOT ADD UDC across multiple modes. This is the TOTAL PROGRAM UDC

Rev: 02/18 Total Program UDC is determined by Provider/System of Care and is based on total target UDC across entire program.

HHS Cost Caps Worksheet	Something Else Non-HHS	Non-Medical Case Management	Treatment Adherence	Peer Advocacy
Cost Caps for HHS Service Categories appear in the boxes to the right based on your selection(s) in the drop-down menus in cells C8, E8, G8 above. The corresponding Unit of Service Type appears in cells C47, E47, and G47. Many cost caps are determined by the degree, license, or experience the staff hold.	ERROR:#N/A	$150 per hour.

$150 per hour maximum for medical (RN) or PhD;

$120 maximum for licensed staff* $105 maximum for Master’s level* $85 for Bachelor’s level under supervision; and $75 for peer under supervision.

* Rate for licensed eligible staff is negotiable between $105 to $120 per hour. Individual $150 per hour.

$150 maximum for medical provide (RN) or PhD;

$120 maximum for licensed staff* $105 maximum for Master’s level* $85 for Bachelor’s level under supervision; and $75 for peer under supervision.

* Rate for licensed eligible staff is negotiable between $105 to $120 per hour.

Groups $240 per hour $240 maximum for medical provider (RN);

$180 maximum for licensed staff;

$120 maximum for all non-licensed $75 per hour

From the Cost Caps tables above, enter in the blue box the cost cap amount for the level of service your agency provides: $ - $ 105.00 $ 75.00 $ 75.00

Your cost per UOS from row 49 above: ERROR:#DIV/0! $ 71.79 ERROR:#DIV/0! ERROR:#DIV/0!

Your cost per UOS is over or (under) the cost cap by this amount: ERROR:#DIV/0! $ (33.21) ERROR:#DIV/0! ERROR:#DIV/0! <== If your cost exceeds the Cost Cap the cell will be RED.

<== If your cost is at or below the Cost Cap the cell will be GREEN.

Bdgt Justf B-1 Pg 2

BUDGET JUSTIFICATION

Contractor Name

ABC CBO

Appendix:

B-1

Program Name:

Ending the HIV Epidemic Intensive Case Management

Appendix Term:

Funding Source:

1a) SALARIES

NOTE: Some federal funding sources (such as a HRSA) have a salary cap. Ryan White 2023 salary cap = $212,100.

If you have a salaried position over the cap and are unsure how to proceed please check in with your CDTA Program Manager.

Staff Position 1

Medical Case Manager

Example Staff Position 1:

Program Director

Brief duties related to this program and clients served

Provides medical case management to clients, ensuring engagement in medical care and reaching viral suppression, responsible to participate in client case conferencing and entering data in ARIES

Brief description of job duties and direct service role:

Provides primary medical care to program clients including an initial risk assessment, history and physical, ordering pertinent labs. Requires working with a multidisciplinary team to assess patients on an ongoing

Degree, license (if applicable), experience

MSW with two or more years experience providing case management to this target population

Degree, license (if applicable), experience :

MD license, 15 hrs of HIV-related CME annually, and direct care of at least 20 HIV+ patients annually, 5 yrs experience.

Annual Salary

x Base FTE

x Mos per Yr

Annualized FTE if < 12 mo

Total

Example Annual Salary:

x FTE:

x Mos per Year:

Annualized FTE if < 12 mo

Total

60,000

1.00

0.67

$ 40,000

$212,100.00

1.00

0.67

$141,400

Staff Position 2:
Brief duties related to this program and clients served
Degree, license (if applicable), experience	LCSW
	Annual Salary	x Base FTE	x Mos per Yr	Annualized FTE if < 12 mo	Total
			12	0.00	$ - 0

Staff Position 3:
Brief duties related to this program and clients served
Degree, license (if applicable), experience
	Annual Salary	x Base FTE	x Mos per Yr	Annualized FTE if < 12 mo	Total
			12	0.00	$ - 0

Staff Position 4:
Brief duties related to this program and clients served
Degree, license (if applicable), experience
	Annual Salary	x Base FTE	x Mos per Yr	Annualized FTE if < 12 mo	Total
			12	0.00	$ - 0

Staff Position 5:
Brief duties related to this program and clients served
Degree, license (if applicable), experience
	Annual Salary	x Base FTE	x Mos per Yr	Annualized FTE if < 12 mo	Total
			9	0.00	$ - 0

Staff Position 6:
Brief duties related to this program and clients served
Degree, license (if applicable), experience
	Annual Salary	x Base FTE	x Mos per Yr	Annualized FTE if < 12 mo	Total
				0.00	$ - 0

Staff Position 7:
Brief duties related to this program and clients served
Degree, license (if applicable), experience
	Annual Salary	x Base FTE	x Mos per Yr	Annualized FTE if < 12 mo	Total
				0.00	$ - 0

Staff Position 8:
Brief duties related to this program and clients served
Degree, license (if applicable), experience
	Annual Salary	x Base FTE	x Mos per Yr	Annualized FTE if < 12 mo	Total
				0.00	$ - 0

Staff Position 9:
Brief duties related to this program and clients served
Degree, license (if applicable), experience
	Annual Salary	x Base FTE	x Mos per Yr	Annualized FTE if < 12 mo	Total
				0.00	$ - 0

Staff Position 10:
Brief duties related to this program and clients served
Degree, license (if applicable), experience
	Annual Salary	x Base FTE	x Mos per Yr	Annualized FTE if < 12 mo	Total
				0.00	$ - 0
	Total FTE, Base:	1.00	Annualized:	0.67

1b) EMPLOYEE FRINGE BENEFITS:		Total Salaries:	$ 40,000
(Components provided below are samples only. The budgeted components should reflect the contractor's ledger accounts.)
	Component	Cost
	Social Security	$ 3,060.00		7.65%	<== Changing these percentages will automatically update the amounts in Fringe Benefits
	Retirement	$ 1,920.00		4.80%
	Medical	$ 5,700.00		14.25%
	Dental	$ 400.00		1.00%
	Unemployment Insurance	$ 880.00		2.20%
	Disability Insurance	$ - 0		0.00%
	Paid Time Off	$ - 0		0.00%
	Other (specify):	$ - 0		0.00%
		Total Fringe Benefit:	$ 11,960	29.90%

Fringe Benefit %: 29.90% <== Cell and number are red if Fringe Benefit rate exceeds 30%. Please complete a Fringe Benefit Rate Increase Request Form to request approval for a rate higher than 30%. The form may be found on the CDTA website under Procedures and Guidelines.

TOTAL SALARIES & EMPLOYEE FRINGE BENEFITS: $ 51,960

2) OPERATING EXPENSES:

Occupancy:	(HHS funded programs must use Appropriate Cost Allocation Methodology)
	Concise/ Specific Description
Expense Item		Rate/Formula	Cost	Expense Item	Brief Description	Rate	Cost
Rent	9% of agency space used by program x	9% x $10,500 x 12 mos.	$ 11,340	Example: Rent	600 square feet for program	$58.50 per square foot	35,100
				Example: Rent	12.5% of Total FTE	12.5% of $73,066	9,133
				For assistance with creating Appropriate Cost Allocation Methodologies please contact your CDTA Program Manager.

		NOTE: You must be consistent in application of Cost Allocation Methodologies across other line items (re: % of cost allocation applied to total operating cost item)
Total Occupancy:	$ 11,340

Materials & Supplies:

Expense Item	Concise/ Specific Description	Rate/Formula	Cost	Expense Item	Brief Description	Rate	Cost
				Example: Office Supplies	Pens, paper, print cartridges	12.5% of FTE x 12000 total	1,500

Total Materials & Supplies: $ - 0

General Operating:

Expense Item	Brief Description	Rate/Formula	Cost	Expense Item	Brief Description	Rate	Cost
				Example: Training/Staff Development	Annual CPR/First Aid certification	$100/person	1,200

	Total General Operating:	$ - 0
Staff Travel:

Purpose of Travel	Location	Expense Item	Rate/Formula	Cost	Purpose of Travel	Location	Expense Item	Rate	Cost
					Example: Grantee Conference	Washington, D.C.	Airfare	$600/flight x 2 persons	1,200

	Total Staff Travel:	$ - 0
Consultants/Subcontractors:

Consult/Subcontractor Name	Service Description	Rate/Formula	Cost	Consultant/Subcontractor Name	Service Description	Rate	Cost
				Example: Trainers Inc.	Conduct Health Education trainings at area schools 4 times per year	$500/training	2,000

	Total Consultants/Subcontractors:	$ - 0
Other:

Expense Item	Brief Description	Rate/Formula	Cost	Expense Item	Brief Description	Rate	Cost
				Example: Client Stipends	Gift cards to encourage client participation	$50/card x 20 cards	1,000

Total Other: $ - 0

TOTAL OPERATING EXPENSES: $ 11,340

	TOTAL DIRECT COSTS:	$ 63,300
4) INDIRECT COSTS
Please list here the personnel and ledger expenses that are included in your shared costs?
		Amount
		$ 5,697

Indirect Rate:	9.00%	NOTE: HHS Ryan White funded programs have a cap of 9% for Indirect Rate
TOTAL INDIRECT COSTS:	$ 5,697

TOTAL EXPENSES: $ 68,997

App B-2 Page 1

Contractor Name		Appendix #
Contract Term (mm/dd/yyyy)		Page #
Funding Source		Fiscal Year(s)
		Funding Notification Date
	UOS COST ALLOCATION BY SERVICE MODE

		SERVICE MODES
Personnel Expenses								Contract Totals
Position Titles	FTE	Salaries	% FTE	Salaries	% FTE	Salaries	% FTE		Category Totals From Bgt Justification
0	- 0		0%		0%		0%	-	$ - 0	Note: Links provided to default Budget Justification. If rows or columns have been added or deleted, check links to update
0	- 0	-	0%	-	0%	-	0%	-	$ - 0
0	- 0	-	0%	-	0%	-	0%	-	$ - 0
0	- 0	-	0%	-	0%	-	0%	-	$ - 0
0	- 0	-	0%	-	0%	-	0%	-	$ - 0
0	- 0	-	0%	-	0%	-	0%	-	$ - 0
Total FTE & Total Salaries	- 0	-	0%	-	0%	-	0%	-	$ - 0
Fringe Benefits	0%	-	0%	-	0%	-	0%	-	$ - 0
Total Personnel Expenses		-	0%	-	0%	-	0%	-	$ - 0

Operating Expenses	Expenditure	%	Expenditure	%	Expenditure	%	Contract Total		Note: These should be the same operating expense categories that show up on the invoice template
Total Occupancy	-	0%	-	0%	-	0%	-	$ - 0
Total Materials and Supplies	-	0%	-	0%	-	0%	-	$ - 0
Total General Operating	-	0%	-	0%	-	0%	-	$ - 0
Total Staff Travel	-	0%	-	0%	-	0%	-	$ - 0
Consultants/Subcontractor:	-	0%	-	0%	-	0%	-	$ - 0
Other (specify):	-	0%	-	0%	-	0%	-	$ - 0
		0%		0%		0%	-
		0%		0%		0%	-
		0%		0%		0%	-
		0%		0%		0%	-
		0%		0%		0%
Total Operating Expenses	-	0%	-	0%	-	0%	-	$ - 0

Capital Expenses	Expenditure	%	Expenditure	%	Expenditure	%	Contract Total
Capital Expenditure 1	-	0%	-	0%	-	0%	-	$ - 0
Capital Expenditure 2		0%		0%		0%	-	$ - 0
Total Capital Expenses	-	0%	-	0%	-	0%	-	$ - 0

Total Direct Expenses		-	0%	-	0%	-	0%	-	$ - 0
Indirect Expenses	0%		0%		0%		0%	-	$ - 0	0%
TOTAL EXPENSES		-	0%	-	0%	-	0%	-	$ - 0

Units of Service (UOS) per Service Mode	-	-	-	-
Cost Per Unit of Service by Service Mode	- 0	- 0	- 0
Unduplicated Clients (UDC) per Service Mode

Rev. 07/15

B-2 page 2 BgtJustf

BUDGET JUSTIFICATION

Contractor Name	0	Appendix #:
Program Name:	0	Fiscal Year:	12/31/99
1a) SALARIES

Staff Position 1:	Example Staff Position 1:	Program Director
Brief description of job duties:	Example Brief description of job duties:	Provides primary medical care to program clients including an initial risk assessment, history and physical, ordering pertinent labs. Requires working with a multidisciplinary team to assess patients on an ongoing
Minimum qualifications:	Example Minimum qualifications:	MD license, 15 hours of HIV-related CME annually, and the direct care of at least 20 HIV positive patients annually, 5 years experience.

Annual Salary:	x FTE:	x Months per Year:	Annualized (if less than 12 months):	Total	Example Annual Salary:	x FTE:	x Months per Year:	Annualized (if less than 12 months):	Total
			0	$ -	$200,000.00	1.00	8	0.67	$133,333

Staff Position 2:

Brief description of job duties:

Minimum qualifications:

Annual Salary:	x FTE:	x Months per Year:	Annualized (if less than 12 months):	Total
			0	$ -

Staff Position 3:

Brief description of job duties:

Minimum qualifications:

Annual Salary:	x FTE:	x Months per Year:	Annualized (if less than 12 months):	Total
			0	$ -

Staff Position 4:

Brief description of job duties:

Minimum qualifications:

Annual Salary:	x FTE:	x Months per Year:	Annualized (if less than 12 months):	Total
			0	$ -

Staff Position 5:

Brief description of job duties:

Minimum qualifications:

Annual Salary:	x FTE:	x Months per Year:	Annualized (if less than 12 months):	Total
			0	$ -

Staff Position 6:

Brief description of job duties:

Minimum qualifications:

Annual Salary:	x FTE:	x Months per Year:	Annualized (if less than 12 months):	Total
			0	$ -

Total FTE: - 0 Total Salaries: $ -

1b) EMPLOYEE FRINGE BENEFITS:
(Components provided below are samples only. The budgeted components should reflect the contractor's ledger accounts.)
Component	Cost
Social Security
Retirement
Medical
Dental
Unemployment Insurance
Disability Insurance
Paid Time Off
Other (specify):
	Total Fringe Benefit:	- 0

Fringe Benefit %: 0%

TOTAL SALARIES & EMPLOYEE FRINGE BENEFITS: - 0

2) OPERATING EXPENSES:

Occupancy:

Expense Item	Brief Description	Rate	Cost	Expense Item	Brief Description	Rate	Cost
				Example: Rent	Rental of program clinic space at 1234 A Street	$3000/month	36,000

	Total Occupancy:	- 0
Materials & Supplies:

Expense Item	Brief Description	Rate	Cost	Expense Item	Brief Description	Rate	Cost
				Example: Office Supplies	Pens, paper, print cartridges	$200/month	2,400

Total Materials & Supplies: - 0

General Operating:

Expense Item	Brief Description	Rate	Cost	Expense Item	Brief Description	Rate	Cost
				Example: Training/Staff Development	Annual CPR/First Aid certification	$100/person	1,200

	Total General Operating:	- 0
Staff Travel:

Purpose of Travel	Location	Expense Item	Rate	Cost	Purpose of Travel	Location	Expense Item	Rate	Cost
					Example: Grantee Conference	Washington, D.C.	Airfare	$200/flight x 2 persons	400

	Total Staff Travel:	- 0
Consultants/Subcontractors:

Consultant/Subcontractor Name	Service Description	Rate	Cost	Consultant/Subcontractor Name	Service Description	Rate	Cost
				Example: Trainers Inc.	Conduct Health Education trainings at area schools 4 times per year	$500/training	2,000

	Total Consultants/Subcontractors:	- 0
Other:

Expense Item	Brief Description	Rate	Cost	Expense Item	Brief Description	Rate	Cost
				Example: Client Stipends	Gift cards to encourage client participation	$50/card x 20 cards	1,000

Total Other: - 0

		TOTAL OPERATING EXPENSES:	- 0
3) CAPITAL EXPENDITURES: (If needed. A unit valued at $5,000 or more)
Capital Expenditure Item	Brief Description		Cost	Capital Expenditure Item	Brief Description	Cost
				Example: Kitchen Remodel	Upgrade of kitchen area to expand vocational training program	15,000

TOTAL CAPITAL EXPENDITURES: - 0

	TOTAL DIRECT COSTS:	- 0
4) INDIRECT COSTS

Describe method and basis for Indirect Cost Allocation (i.e., FTE, square footage, or other) Amount

Indirect Rate:	0%
TOTAL INDIRECT COSTS:	- 0

TOTAL EXPENSES: - 0

App B-3 Page 1

Contractor Name		Appendix #
Contract Term (mm/dd/yyyy)		Page #
Funding Source		Fiscal Year(s)
		Funding Notification Date
	UOS COST ALLOCATION BY SERVICE MODE

		SERVICE MODES
Personnel Expenses								Contract Totals
Position Titles	FTE	Salaries	% FTE	Salaries	% FTE	Salaries	% FTE		Category Totals From Bgt Justification
0	- 0		0%		0%		0%	-	$ - 0	Note: Links provided to default Budget Justification. If rows or columns have been added or deleted, check links to update
0	- 0	-	0%	-	0%	-	0%	-	$ - 0
0	- 0	-	0%	-	0%	-	0%	-	$ - 0
0	- 0	-	0%	-	0%	-	0%	-	$ - 0
0	- 0	-	0%	-	0%	-	0%	-	$ - 0
0	- 0	-	0%	-	0%	-	0%	-	$ - 0
Total FTE & Total Salaries	- 0	-	0%	-	0%	-	0%	-	$ - 0
Fringe Benefits	0%	-	0%	-	0%	-	0%	-	$ - 0
Total Personnel Expenses		-	0%	-	0%	-	0%	-	$ - 0

Operating Expenses	Expenditure	%	Expenditure	%	Expenditure	%	Contract Total		Note: These should be the same operating expense categories that show up on the invoice template
Total Occupancy	-	0%	-	0%	-	0%	-	$ - 0
Total Materials and Supplies	-	0%	-	0%	-	0%	-	$ - 0
Total General Operating	-	0%	-	0%	-	0%	-	$ - 0
Total Staff Travel	-	0%	-	0%	-	0%	-	$ - 0
Consultants/Subcontractor:	-	0%	-	0%	-	0%	-	$ - 0
Other (specify):	-	0%	-	0%	-	0%	-	$ - 0
		0%		0%		0%	-
		0%		0%		0%	-
		0%		0%		0%	-
		0%		0%		0%	-
		0%		0%		0%
Total Operating Expenses	-	0%	-	0%	-	0%	-	$ - 0

Capital Expenses	Expenditure	%	Expenditure	%	Expenditure	%	Contract Total
Capital Expenditure 1	-	0%	-	0%	-	0%	-	$ - 0
Capital Expenditure 2		0%		0%		0%	-	$ - 0
Total Capital Expenses	-	0%	-	0%	-	0%	-	$ - 0

Total Direct Expenses		-	0%	-	0%	-	0%	-	$ - 0
Indirect Expenses	0%		0%		0%		0%	-	$ - 0	0%
TOTAL EXPENSES		-	0%	-	0%	-	0%	-	$ - 0

Units of Service (UOS) per Service Mode	-	-	-	-
Cost Per Unit of Service by Service Mode	- 0	- 0	- 0
Unduplicated Clients (UDC) per Service Mode

Rev. 07/15

B-3 page 2 BgtJustf

BUDGET JUSTIFICATION

Contractor Name	0	Appendix #:
Program Name:	0	Fiscal Year:	12/31/99
1a) SALARIES

Staff Position 1:	Example Staff Position 1:	Program Director
Brief description of job duties:	Example Brief description of job duties:	Provides primary medical care to program clients including an initial risk assessment, history and physical, ordering pertinent labs. Requires working with a multidisciplinary team to assess patients on an ongoing
Minimum qualifications:	Example Minimum qualifications:	MD license, 15 hours of HIV-related CME annually, and the direct care of at least 20 HIV positive patients annually, 5 years experience.

Annual Salary:	x FTE:	x Months per Year:	Annualized (if less than 12 months):	Total	Example Annual Salary:	x FTE:	x Months per Year:	Annualized (if less than 12 months):	Total
			0	$ -	$200,000.00	1.00	8	0.67	$133,333

Staff Position 2:

Brief description of job duties:

Minimum qualifications:

Annual Salary:	x FTE:	x Months per Year:	Annualized (if less than 12 months):	Total
			0	$ -

Staff Position 3:

Brief description of job duties:

Minimum qualifications:

Annual Salary:	x FTE:	x Months per Year:	Annualized (if less than 12 months):	Total
			0	$ -

Staff Position 4:

Brief description of job duties:

Minimum qualifications:

Annual Salary:	x FTE:	x Months per Year:	Annualized (if less than 12 months):	Total
			0	$ -

Staff Position 5:

Brief description of job duties:

Minimum qualifications:

Annual Salary:	x FTE:	x Months per Year:	Annualized (if less than 12 months):	Total
			0	$ -

Staff Position 6:

Brief description of job duties:

Minimum qualifications:

Annual Salary:	x FTE:	x Months per Year:	Annualized (if less than 12 months):	Total
			0	$ -

Total FTE: - 0 Total Salaries: $ -

1b) EMPLOYEE FRINGE BENEFITS:
(Components provided below are samples only. The budgeted components should reflect the contractor's ledger accounts.)
Component	Cost
Social Security
Retirement
Medical
Dental
Unemployment Insurance
Disability Insurance
Paid Time Off
Other (specify):
	Total Fringe Benefit:	- 0

Fringe Benefit %: 0%

TOTAL SALARIES & EMPLOYEE FRINGE BENEFITS: - 0

2) OPERATING EXPENSES:

Occupancy:

Expense Item	Brief Description	Rate	Cost	Expense Item	Brief Description	Rate	Cost
				Example: Rent	Rental of program clinic space at 1234 A Street	$3000/month	36,000

This is the start of the file's text. The full file is on GovTribe.

File details come from the government source that posted it. Updated Aug 17, 2026.