Form 1B Funding-request-summary.pdf
PDF 178 KB Posted
- Attached to
- Fiscal Year 2027 Expanding Nutrition Services
- Opportunity number
- HRSA-27-099
About this file
This is HRSA Form 1B: Funding Request Summary, a required document for Health Center Program grant applications under section 330 of the Public Health Service Act. The form is managed by the Health Resources and Services Administration (HRSA) and has OMB control number 0915-0285, valid through April 30, 2026. Applicants must use this form to document their federal funding request, which should align with the total federal funds requested on the SF-424A budget form. The form specifically addresses one-time funding requests for equipment and minor alterations/renovations (A/R), with four mutually exclusive options: no funding requested, equipment only, minor A/R with equipment, or minor A/R without equipment.
Completion of supplementary forms is contingent upon the one-time funding selection. If equipment only is indicated, applicants must complete the Equipment List form. If minor A/R with equipment is selected, applicants must complete the Equipment List, A/R Project Cover Page, and Other Requirements for Sites forms. If minor A/R without equipment is selected, applicants must complete the A/R Project Cover Page and Other Requirements for Sites forms. If no one-time funding is requested, none of these supplementary forms are required. The estimated public reporting burden for completing this information collection is 45 minutes per response, and the form applies to section 330 grant-funded health centers and Federally Qualified Health Center look-alikes delivering comprehensive primary health care regardless of patient ability to pay.
Form 1B Funding-request-summary.pdf
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Other files
| File | Type | Posted |
|---|---|---|
| H80 Grant Number Form.pdf | ||
| Other Requirements for Sites Form.pdf | ||
| Minor AR Project Cover Page Form.pdf | ||
| Equipment List Form.pdf | ||
| EID Checklist Form.pdf | ||
| FOA Content HRSA-27-099 Final v2.pdf |
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Text version
OMB No.: 0915-0285. Expiration Date: 04/30/2026
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
Note the following when completing this form:
• The Federal Funding Request below should match the Total Federal Funds requested on the
SF-424A.
• The one-time funding request below totals the Equipment and Construction (minor A/R) federal line items on the SF-424A.
Federal Funding Request
One-time Funding Request
You indicated on the Budget Information form, Section B that you are requesting one-time funding for:
N/A (no funding requested for equipment or minor A/R) Equipment (no minor A/R) Minor alteration/renovation with equipment Minor alteration/renovation without equipment
One-time funding request for minor A/R and equipment:
NOTE:
If no funding is requested for equipment or minor A/R in the Budget Information form, you will not use the following forms in your application: Equipment List, A/R Project Cover Page, and Other Requirements for Sites.
If 'Equipment (no minor A/R)’ is indicated above, you must complete the Equipment List form.
If 'Minor A/R with equipment' is indicated above, you must complete the Equipment List, A/R
Project Cover Page, and Other Requirements for Sites forms.
If 'Minor A/R without equipment' is indicated above, you must complete the A/R Project Cover
Page and Other Requirements for Sites forms.
Based on your one-time funding request, you are required to complete the applicable equipment and/or minor A/R forms.
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. The Health Center Program application forms provide essential information to HRSA staff and objective review committee panels for application evaluation; funding recommendation and approval; designation; and monitoring. The OMB control number for this information collection is 0915-0285 and it is valid until 04/30/2026. This information collection is mandatory under the Health Center Program authorized by section 330 of the Public Health Service (PHS) Act (42 U.S.C. 254b). Public reporting burden for this collection of information is estimated to average 45 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 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov.
https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section254b&num=0&edition=prelim mailto:paperwork@hrsa.gov
FORM 1B: FUNDING REQUEST SUMMARY
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