Attachment_5_-_Cost_Breakdown_Form_2016_-_ACIOP.docx

Attachment 5 RFQ No. NIHLM2016769-GB

Attachment 5 RFQ No.

Cost Breakdown Form

HIV/AIDS Community Information Outreach Project 2016

Organization: _____________________ Date Submitted: _________________

Period Covered: ________________________

EXPENDITURE CATEGORY

COST

DIRECT LABOR

PROFESSIONAL PERSONNEL

SUPPORT PERSONNEL

FRINGE BENEFITS

EQUIPMENT

SUPPLIES

TRAVEL

COMMUNICATIONS

REPRODUCTION

OTHER COSTS (SPECIFY)

CONSULTANTS

DOCUMENT DELIVERY

TOTAL DIRECT COST

[MODIFIED TOTAL DIRECT COST]

OVERHEAD/IDC (____ %)

TOTAL

Does your organization currently have a negotiated indirect cost rate agreement with any U.S. Government agency? __Yes __ No (If Yes, please identify agency________________________________________)

Will you require the purchase of equipment in the performance of this proposed contract? Yes __ No __

Do you now hold any contract for the same or similar work called for by this proposed solicitation with any other government agency? __ Yes __ No (If yes, please identify contract and agency_______________ ____________________________________________________________________________________)

· If travel is proposed, provide statement addressing the following details on destination(s); duration of trip(s); number of travelers; and cost per trip, broken down by cost elements, e.g., airfare, lodging, and meals.

· If consultants are proposed, provide name(s), rate(s), and number of hours/days.

NOTE: The above categories are examples only and are not meant to be all-inclusive. Additionally, funds may not be used for the following:

· Facility or room rental expenses;

· Purchase of meals, light refreshments, or beverages, including gift cards for such items;

· Gifts, gift cards, or promotional items including, but not limited to: clothing and commemorative items such as pens, mugs/cups, folders/folios, lanyards, conference bags or similar items.