Schedule 2 - Budget Form.xls
XLS spreadsheet 253 KB Posted
- Solicitation number
- S-0627 DCTS-17
- Issued by
- Wisconsin
About this file
This is a Schedule 2 Budget Form from the Wisconsin Department of Health Services (DHS), Division of Care and Treatment Services, for Request for Bid (RFB) No. S-0627 DCTS-17 to perform Preadmission Screening and Resident Reviews (PASRR) Level II screens for nursing home residents in Wisconsin. The budget form is designed to document one year of operations based on an estimated 11,000 completed PASRR Level II screens, consistent with 2016 volumes. The form requires vendors to complete detailed budget documentation across multiple sections, including salary and personnel costs, fringe benefits, equipment, operating expenses, supplies, travel (in-state and out-of-state), consultant and contractual costs, training, insurance and surety bonds, advertising and public information, consumer/family reimbursement, and other costs. The budget must be submitted in Excel format and include both summary line items and detailed sub-budgets with supporting justifications for each expense category.
The budget form establishes specific instructions for cost allocation and documentation while clarifying that certain Wisconsin Allowable Cost Policy provisions do not apply to this contract, including references to depreciation rates, state-approved mileage rates, federal per diem and lodging limitations, and the 10% indirect cost limit. Vendors must include profit as an "Other" cost within the spreadsheet and are permitted to use federally-approved indirect cost rates or up to 10% if no federally-approved rate exists. The form accommodates both prime contractor budgets (Parts 1 and 2) and subcontractor budgets (Parts 3 and 4), with subcontractor sections to be completed only if subcontractors will be utilized. All salary information must align with the Work Plan submitted in Schedule 4, and the budget does not need to tie out to the cost-per-screen bid amount, serving primarily as an informational document to ensure bid viability.
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Overview
| The budget form includes four parts. Parts 1 and 2 includes summary line item budget and detailed budget tables and explanatory text boxes that document how individual budget line items are derived for the Prime Contractor. Parts 3 and 4 including the same type of information for a subcontractor, if any. | |
| Complete Schedule 2 - Budget Form using these general instructions and the detailed instructions for each worksheet and section including the detailed budget tables and explanatory text boxes that document how individual budget line items are derived. Profit is to be identified as an “Other” cost within the spreadsheet. | |
| The information submitted in Schedule 2: | |
| a. | Will insure that the bid is viable. |
| b. | Will be reviewed to confirm the cost per screen bid is based on a reasonable expenses including those established in the Wisconsin Allowable Cost Policy Manual. |
| c. | Provides a baseline on which to base renegotiations of any requested increases in the cost per screen over the 6-year life of the contract |
| d. | Does not need to tie out to the cost per screen bid. |
| e. | Will insure that the bid is viable. |
| NOTE: This Schedule 2-Budget Form is based on DHS Form 01601 which is used for the application process and implementation of grant programs administered by the DHS Division of Care and Treatment Services. The form makes use of grant-related terms like “grant funds”, “applicant”, “indirect cost rate”, “proposal” and other like words and phrases. For purposes of this Request For Bid, the word “contract” should be used in lieu of references grant-funds, “Vendor” should be used in lieu of references to applicant, and references to the Federal Indirect Rate do not apply. | |
| When completing Schedule 2: | |
| 1) Complete Schedule 2 to reflect one year of operations including 11,000 completed PASRR Level II Screens. This is the number of screens completed in CY 2016. This value is being used as an estimate for this completing this budget form. Schedule 2 is for informational purposes only and does not need to tie out to the cost per screen bid. Note: There is no guarantee as to volume of screens per contract year. | |
| 2) There are several references to “Work Plan”. For purposes of this RFB, Work Plan refers to the information submitted in Schedule 4 – Work Plan, Organization, and Staffing. | |
| 3) Part 1, cell A:24, leave blank | |
| 4) Part 2 | |
| a) Row 29, enter “See Schedule 4” and include this information in Schedule 4 – Work Plan, Organization, and Staffing. | |
| b) Row 59 references Allowable Cost Policy related to depreciation. Those provisions do not apply to this RFB. | |
| c) Row 94 references to “state-approved rates”, mileage rate limitations, and federal per diem and lodging rates to not apply to this RFB. | |
| d) Row 109, as with row 94, the limitations do not apply to this RFB. | |
| e) Row 146, enter “See Schedule 4” and include this information in Schedule 4 – Work Plan, Organization, and Staffing. | |
| f) Rows 181 through 190, leave blank. Section L Consumer/Family Reimbursement is not part of this contract. | |
| g) Row 207, references to the 10% limit and “cannot exceed the agency’s federal-approved rate” do not apply to this RFB. | |
| Note: Only complete Parts 3 and 4 if a subcontractor will be used. Otherwise, leave blank. | |
| 5) Part 3, cell A:24, leave blank. | |
| 6) Part 4 | |
| a) Row 29, enter “See Schedule 4” and include this information in Schedule 4 – Work Plan, Organization, and Staffing. | |
| b) Row 59 references Allowable Cost Policy related to depreciation. Those provisions do not apply to this RFB. | |
| c) Row 94 references to “state-approved rates”, mileage rate limitations, and federal per diem and lodging rates to not apply to this RFB. | |
| d) Row 109, as with row 94, the limitations do not apply to this RFB. | |
| e) Row 146, enter “See Schedule 4” and include this information in Schedule 4 – Work Plan, Organization, and Staffing. | |
| f) Rows 181 through 190, leave blank. Section L Consumer/Family Reimbursement is not part of this contract. | |
| g) Row 207, references to the 10% limit and “cannot exceed the agency’s federal-approved rate” do not apply to this RFB. |
&CSchedule 2 - Budget Form
OVERVIEW AND GENERAL INSTRUCTIONS
&LRFB No. S-0627 DCTS-17&CSchedule 2 - Budget Form &A&RPage &P of &N
Part 1-Contractor summary
| Name of Organization: | [Enter company name here] | ||
| Contract Period: | [Enter Date here] | ||
| General Instructions: Your budget document must be filled out and submitted in Excel. Do not submit a “PDF” Adobe Acrobat copy of your budget document. You have been provided two budget forms. Part 1 (found below) is a summary line item budget and Part 2 is a series of detailed budget tables and explanatory text boxes that document how individual budget line items are derived. Note: Each item requested in the budget can only appear under one Annual Line Item Budget category. | |||
| Annual Line Item Budget | Dollar Amt. | Fill Out Detailed Sub-Budget | Additional Detail Required |
| A - SALARY/PERSONNEL COSTS | $0.00 | Go to Part 2 | Provide justification on Part 2 |
| B - FRINGE BENEFIT COSTS | $0.00 | Go to Part 2 | Provide justification on Part 2 |
| C - EQUIPMENT COSTS | $0.00 | Go to Part 2 | Provide justification on Part 2 |
| D - OPERATING EXPENSES | $0.00 | Go to Part 2 | Provide justification on Part 2 |
| E - SUPPLIES | $0.00 | Go to Part 2 | Provide justification on Part 2 |
| F - IN STATE TRAVEL | $0.00 | Go to Part 2 | Provide justification on Part 2 |
| G - OUT-OF-STATE TRAVEL | $0.00 | Go to Part 2 | Provide justification on Part 2 |
| H - CONSULTANT/CONTRACTUAL COSTS | $0.00 | Go to Part 2 | Provide justification on Part 2 |
| I - TRAINING | $0.00 | Go to Part 2 | Provide justification on Part 2 |
| J - INSURANCE & SURETY BONDS | $0.00 | Go to Part 2 | Provide justification on Part 2 |
| K - ADVERTISING & PUBLIC INFORMATION | $0.00 | Go to Part 2 | Provide justification on Part 2 |
| L - CONSUMER/FAMILY REIMBURSEMENT | $0.00 | Go to Part 2 | Provide justification on Part 2 |
| M - OTHER | $0.00 | Go to Part 2 | Provide justification on Part 2 |
| N - SUBTOTAL - DIRECT COSTS (SUM of A-M) | $0.00 | ||
| O - INDIRECT COSTS | $0.00 | Go to Part 2 | Provide justification on Part 2. Attach letter documenting federally approved indirect cost rate. |
| P - TOTAL COSTS (N + O), Rounded to the nearest dollar. | $0.00 | ||
| LINE P MUST NOT EXCEED $______ [Contract Administrator to fill in above amount] |
&L&"Arial,Bold"Department of Health Services&"Arial,Regular" Division of Care and Treatment Services F-01601 (09/2016)&C&"Arial,Bold"&12 Summary Line Item Budget: Part 1&R&"Arial,Bold"STATE OF WISCONSIN &LRFB No. S-0627 DCTS-17&CSchedule 2 - Budget Form &A&R&P of &N &L&"Arial,Bold"&9Department of Health Services &"Arial,Regular"Division of Mental Health & Substance Abuse Services F-____ (8/2015)&C&"Arial,Bold"&9DMHSAS Summary Line Item Budget: Part 1&R&"Arial,Bold"&9STATE OF WISCONSIN &R&P of &N &L&"Arial,Bold"&9Department of Health Services &"Arial,Regular"Division of Mental Health & Substance Abuse Services F-____ (8/2015)&C&"Arial,Bold"&12Exhibit 2 -- DMHSAS Budget Form: Part 1&R&"Arial,Bold"&9State of Wisconsin &L&Z&F&R&P of &N
Part 2-Contractor detail
| Name of Organization: | [Enter company name here] | ||||
| Contract Period: | [Enter Date here] | ||||
| A: SALARY DETAIL SUB-BUDGET | |||||
| Instructions: Use salary detail columns to calculate costs. Column B: Enter title of each position funded by the grant. Column C: Enter either hourly (hourly employees) OR monthly rate of pay (monthly salaried employees) for grant-funded employees. Column D & E: Enter number of hours per week AND # of weeks for hourly employees, OR # of months, and % FTE per monthly salaried employees. Column F: Totals in this column are locked to calculate the total cost automatically. The following equations are used to calculate salary cost for each line: For hourly positions (“Hourly rate” * “Hours per week” * ”# of weeks”); for monthly positions (“Monthly rate” * "% FTE" * ”# of months”). Include only costs covered by this grant proposal or application. Do not include salary costs covered by other funding sources. Pay rates should be reasonable when considering the position titles. Total cost for each position should be calculated based on the length of the contract (e.g., 12-month vs. short-term or late-start contract). Note: Position titles must be consistent with the Work Plan. If you need to add lines for additional positions: highlight Row 16 (for hourly employees) OR Row 26 for (monthly salaried employees), right click on the row and select insert. Repeat for as many additional rows as you need. Enter the information for the additional positions following the instructions above. | |||||
| Position Title (Be Specific) | Hourly Pay Rate | Hours paid per Week | # of weeks paid in contract period | Total Cost | |
| Hourly Employee Salary Item 1 | $0.00 | 0.00 | 0.00 | $0.00 | |
| Hourly Employee Salary Item 2 | $0.00 | 0.00 | 0.00 | $0.00 | |
| Hourly Employee Salary Item 3 | $0.00 | 0.00 | 0.00 | $0.00 | |
| Hourly Employee Salary Item 4 | $0.00 | 0.00 | 0.00 | $0.00 | |
| Hourly Employee Salary Item 5 | $0.00 | 0.00 | 0.00 | $0.00 | |
| Hourly Employee Salary Item 6 | $0.00 | 0.00 | 0.00 | $0.00 | |
| Hourly Employee Salary Item 7 | $0.00 | 0.00 | 0.00 | $0.00 | |
| Hourly Employee Salary Item 8 | $0.00 | 0.00 | 0.00 | $0.00 | |
| Hourly Employee Salary Item 9 | $0.00 | 0.00 | 0.00 | $0.00 | |
| Position Title (Be Specific) | 1 FTE Monthly Pay Rate | % FTE | # of months paid in contract period | ||
| Monthly Salaried Employee Item 10 | $0.00 | 0.00% | 0.00 | $0.00 | |
| Monthly Salaried Employee Item 11 | $0.00 | 0.00% | 0.00 | $0.00 | |
| Monthly Salaried Employee Item 12 | $0.00 | 0.00% | 0.00 | $0.00 | |
| Monthly Salaried Employee Item 13 | $0.00 | 0.00% | 0.00 | $0.00 | |
| Monthly Salaried Employee Item 14 | $0.00 | 0.00% | 0.00 | $0.00 | |
| Monthly Salaried Employee Item 15 | $0.00 | 0.00% | 0.00 | $0.00 | |
| Monthly Salaried Employee Item 16 | $0.00 | 0.00% | 0.00 | $0.00 | |
| Monthly Salaried Employee Item 17 | $0.00 | 0.00% | 0.00 | $0.00 | |
| Monthly Salaried Employee Item 18 | $0.00 | 0.00% | 0.00 | $0.00 | |
| Total Cost (Section A) | $0.00 | ||||
| JUSTIFICATION (Provide a thorough description of the role and responsibilities of each position.) | |||||
| [Enter justification text here] | |||||
| B: FRINGE BENEFIT DETAIL SUB-BUDGET | |||||
| Instructions: Use the fringe benefits detail table to calculate costs. Column B & C: Edit or copy employee titles (Column B in section A) and salaries (column F in Section A). Column D: Enter total fringe benefit rate for each position. Column E: The following equation is used to calculate cost for each line (Salary * Fringe Rate). Provide a description of the components of the fringe rates in the justification box. If the agregate fringe rate is above 45%, a breakdwon of the individual components and additional justification will be required. Fringe benefit components may include items such as Federal Insurance Contributions Act (FICA) and Unemployment Insurance, Retirement, Life Insurance, Workers Compensation and Health Insurance. Only include costs covered by this proposal or application. If you need to add lines for additional positions: highlight Row 51, right click on the row and select insert. Repeat for as many additional rows as you need. Enter the fringe rate information for the additional positions following the instructions above. | |||||
| Position Title (Be Specific) | Salary | Fringe Rate | Total Cost | ||
| Fringe Benefit Item 1 | $0.00 | 0.000% | $0.00 | ||
| Fringe Benefit Item 2 | $0.00 | 0.000% | $0.00 | ||
| Fringe Benefit Item 3 | $0.00 | 0.000% | $0.00 | ||
| Fringe Benefit Item 4 | $0.00 | 0.000% | $0.00 | ||
| Fringe Benefit Item 5 | $0.00 | 0.000% | $0.00 | ||
| Fringe Benefit Item 6 | $0.00 | 0.000% | $0.00 | ||
| Fringe Benefit Item 7 | $0.00 | 0.000% | $0.00 | ||
| Fringe Benefit Item 8 | $0.00 | 0.000% | $0.00 | ||
| Fringe Benefit Item 9 | $0.00 | 0.000% | $0.00 | ||
| Fringe Benefit Item 10 | $0.00 | 0.000% | $0.00 | ||
| Fringe Benefit Item 11 | $0.00 | 0.000% | $0.00 | ||
| Fringe Benefit Item 12 | $0.00 | 0.000% | $0.00 | ||
| Fringe Benefit Item 13 | $0.00 | 0.000% | $0.00 | ||
| Fringe Benefit Item 14 | $0.00 | 0.000% | $0.00 | ||
| Fringe Benefit Item 15 | $0.00 | 0.000% | $0.00 | ||
| Fringe Benefit Item 16 | $0.00 | 0.000% | $0.00 | ||
| Fringe Benefit Item 17 | $0.00 | 0.000% | $0.00 | ||
| Fringe Benefit Item 18 | $0.00 | 0.000% | $0.00 | ||
| Total Cost (Section B) | $0.00 | ||||
| JUSTIFICATION (Describe the various components of the fringe rate as well as the formula used in the calculation. If the fringe rate is above 45%, then additional justification for the percentage as well as a breakdown of the cost of each component, determined either from an annual agency-wide percentage based on a cost study, or from position-specific fringe rates must be included. ) | |||||
| [Enter justification text here] | |||||
| C: EQUIPMENT PURCHASE DETAIL SUB-BUDGET (Only for items of $5,000 or more) | |||||
| Instructions: Enter data ONLY if you are purchasing a piece of equipment valued at $5,000 or more with grant funds. Use detailed table to calculate total costs. Column B: Enter brief description of each equipment item. Column C: Enter number of units of each item to be purchased. Column D: Enter dollar cost for each item. Column E: The following equation is used to calculate costs for each line (# of units * cost per unit). Equipment is defined as an individual non-expendable tangible personal property item with a value of $5,000 or more and a useful life of more than one year. Applicants must follow the Allowable Cost Policy regarding depreciation of equipment. If items collectively cost more than $5,000 but individually cost less (e.g., three workstations at $2,000 apiece), then the items should be reported under "Supplies," not "Equipment." | |||||
| Description | # of Units | Cost per Unit | Total Cost | ||
| Equipment Line Item 1 | 0.00 | $0.00 | $0.00 | ||
| Equipment Line Item 2 | 0.00 | $0.00 | $0.00 | ||
| Equipment Line Item 3 | 0.00 | $0.00 | $0.00 | ||
| Total Cost (Section C) | $0.00 | ||||
| JUSTIFICATION (Describe the purpose for each equipment purchase and how the purchase relates to the work plan.) | |||||
| [Enter justification text here] | |||||
| D: OPERATING COSTS | |||||
| Instructions: Operating expenses are non-supply costs directly related to proposed services and includes (but is not limited to) items such as rent, maintenance, printing and reproduction, land telephone and cellular phone services, utilities, IT support specific to the project, and Internet access. Operating costs can be determined either as direct costs or as an allocation of direct costs. If operating costs are determined by an allocation of direct costs, then the same allocation method should be used to estimate operating costs for all programs supported by the agency. Use detailed table to calculate total costs. | |||||
| Description | # of Units | Cost per Unit | Total Cost | ||
| Operating Cost Line Item 1 | 0.00 | $0.00 | $0.00 | ||
| Operating Cost Line Item 2 | 0.00 | $0.00 | $0.00 | ||
| Operating Cost Line Item 3 | 0.00 | $0.00 | $0.00 | ||
| Total Cost (Section D) | $0.00 | ||||
| JUSTIFICATION (Provide a detailed description of the method used to estimate the operating costs figures, along with a description and the purposes of all items comprising the total operating costs.) | |||||
| [Enter justification text here] | |||||
| E: SUPPLIES PURCHASE DETAIL SUB-BUDGET | |||||
| Instructions: Use detailed table below to calculate costs. Column B: Enter brief description of each supply item or category (such as “laptop computer” or “office paper”). Column C: Enter number of units of each item to be purchased. If using an annual estimate of costs, the # of Units should equal 12 (months). Column D: Enter dollar cost for each item. If estimating an annual cost, enter the monthly cost in Column D and 12 (months) in Column C. Column E: The following equation is used to calculate total cost for each line (# of units * cost per unit). Supplies include consumable office supplies (e.g., postage, paper, pens, desk phones) and any item priced less than $5,000 (e.g., laptops, printers, cell phones) that will be used for purposes under the proposal or application. Items in this category may also include start-up supplies such as office desks, chairs and file cabinets, and program-specific supplies like Urine Assessment kits, medications and printed curricula or materials for clients (e.g., family psycho-educational materials). | |||||
| Description | # of Units | Cost per Unit | Total Cost | ||
| Supply Item 1 | 0.00 | $0.00 | $0.00 | ||
| Supply Item 2 | 0.00 | $0.00 | $0.00 | ||
| Supply Item 3 | 0.00 | $0.00 | $0.00 | ||
| Supply Item 4 | 0.00 | $0.00 | $0.00 | ||
| Supply Item 5 | 0.00 | $0.00 | $0.00 | ||
| Total Cost (Section E) | $0.00 | ||||
| JUSTIFICATION (Please describe the purpose for any supply purchase with a total cost of $500 or greater, and how each item will be used for this program.) | |||||
| [Enter justification text here] | |||||
| F: IN-STATE TRAVEL DETAIL SUB-BUDGET | |||||
| Instructions: Use detailed table below to calculate costs. Mileage: Enter mileage, enter number of miles. Meals: Enter daily meal rate cost and number of days. Lodging: Enter nightly lodging cost & number of nights of lodging. Other: Enter description and total of any other in-state travel costs. Applicant must use the state-approved rates, unless the applicant's board approves use of a higher rate and that rate applies to all agency programs. Rates for mileage cannot exceed current federal General Services Administration privately-owned vehicle rate (See http://www.gsa.gov/portal/content/100715 for updates on federal rate), or exceed allowed federal per diem and lodging rates (See http://www.gsa.gov/portal/category/100000). Reimbursement must be related to grant-funded activities for staff, volunteers or clients, such as site visits or training. | |||||
| Mileage Rate | # of Miles | Total Cost | |||
| Mileage Reimbursement | $0.000 | $0.00 | |||
| Daily Rate | # of Days | ||||
| Meal Reimbursement | $0.00 | $0.00 | |||
| Nightly Lodging rate | # of Nights | ||||
| Lodging Reimbursement | $0.00 | $0.00 | |||
| Describe Cost: | |||||
| Other In-State Travel Costs | [Enter description here] | $0.00 | |||
| Total Cost (Section F) | $0.00 | ||||
| JUSTIFICATION (Please provide a detailed description of how you arrived at the amounts provided above. List the number of trips, the purpose of the travel and destinations, and describe which staff positions will be traveling.) | |||||
| [Enter justification text here] | |||||
| G: OUT-OF-STATE TRAVEL DETAIL SUB-BUDGET | |||||
| Instructions: Use detailed table below to calculate costs. See instructions in Section F above for IN-STATE TRAVEL. Applicant must use the state-approved rates, unless the applicant board approves a higher rate and that rate applies to all agency programs. Rates for mileage cannot exceed current federal General Services Administration privately-owned vehicle rate, or exceed federally-allowable meal, lodging and airfare rates. (See http://www.gsa.gov/portal/content/100715 for updates on federal travel rate. See also http://www.gsa.gov/portal/content/104877 for other federally-allowed rates, and http://oser.state.wi.us/bulletins/bulletin_get.asp?bid=604 for list of 'high cost cities' for lodging). Reimbursement must be related to grant-funded activities for staff, volunteers or clients such as site visits or training. | |||||
| Rate | # of People | Total Cost | |||
| Airfare | $0.00 | $0.00 | |||
| Rate/Roundtrip | # of People | ||||
| Checked baggage | $0.00 | $0.00 | |||
| Rate | # of People | ||||
| Conference/Meeting Registration | $0.00 | $0.00 | |||
| Rate/Ride | # of Rides | ||||
| Transportation (taxi/shuttle) | $0.00 | $0.00 | |||
| Daily Rate | # of People | # of Days | |||
| Meals | $0.00 | $0.00 | |||
| Nightly Rate | # of People | # of Nights | |||
| Lodging | $0.00 | $0.00 | |||
| Mileage Rate | # of People | # of Miles Roundtrip | |||
| Mileage | $0.00 | $0.00 | |||
| Daily Rate | # of Cars | # of Days | |||
| Parking | $0.00 | $0.00 | |||
| Describe Cost | Cost | ||||
| Other Out-of-State Travel Costs | [Enter description here] | $0.00 | |||
| Total Cost (Section G) | $0.00 | ||||
| JUSTIFICATION (Please provide a detailed description of how you arrived at the amounts provided above. List the number of trips, type of travel, rate per trip, the purpose of the travel and destinations, and describe which staff positions will be traveling.) | |||||
| [Enter justification text here] | |||||
| H: CONSULTANT & CONTRACTUAL DETAIL SUB-BUDGET | |||||
| Instructions: Use detailed table below to list total costs. List in the upper portion the total budget cost for contractors/consultants who are individuals or self-employed. List in the lower portion the total budget cost for agency or organization sub-contracts. Complete a detailed subcontractor budget (Part 3 and Part 4) for any contract (either with an individual or agency) when the reasonableness or appropriateness of the expense cannot be determined solely from the Part 2, Section H line items and justification. For example, if the total cost for a contract listed in Section H includes multiple line items i.e. salary, fringe, travel, and supplies going to another agency or individual, then a detailed contractor sub budget should be completed in Parts 3 and 4. | |||||
| Name of Consultant/Contractor | Description of Service | Cost | |||
| Individual Consultant/Contractor #1 | $0.00 | ||||
| Individual Consultant/Contractor #2 | $0.00 | ||||
| Individual Consultant/Contractor #3 | $0.00 | ||||
| Name of Contractor | Description of Service | ||||
| Agency Contractor #1 | $0.00 | ||||
| Agency Contractor #2 | $0.00 | ||||
| Agency Contractor #3 | $0.00 | ||||
| Total Cost (Section H) | $0.00 | ||||
| JUSTIFICATION (Please provide a detailed description of how you arrived at the amounts listed above. Also describe the method used to calculate the amount needed. [Examples may include unit cost and anticipated time or units, hourly rate, or daily rate.] Note also the programming, services or products each contractor/consultant will provide.) | |||||
| [Enter justification text here] | |||||
| I - TRAINING SUB-BUDGET | |||||
| Instructions: Describe total training costs for proposed funded staff, volunteers associated with the proposal or application, and proposed clients. This category may include training costs for staff funded by this grant, volunteers associated with the proposal, and clients of the program. (Note: Training costs covered under Section H cannot also be covered under Section I.) Costs may also include registration fees, speaker fees and costs, meeting rooms, training materials and other supplies, and attendance at program-related conferences. | |||||
| Describe Training Event and/or Trainers | Purpose of Training | Cost | |||
| Training Cost Line Item 1 | $0.00 | ||||
| Training Cost Line Item 2 | $0.00 | ||||
| Training Cost Line Item 3 | $0.00 | ||||
| Total Cost (Section I) | $0.00 | ||||
| JUSTIFICATION (Describe how you arrived at the training cost figure with a description and purpose for all planned training expenditures including the number of persons to receive training. Training costs must align with the program work plan.) | |||||
| [Enter justification text here] | |||||
| J - INSURANCE & SURETY BONDS SUB-BUDGET | |||||
| Instructions: Describe total costs for insurance and surety bonds needed for the proposed services. Costs may include, but are not limited to, liability insurance, auto insurance, property insurance to cover staff while driving, property insurance covering the building or facility, insurance for program directors or officers, and cost of surety bonds. | |||||
| Name of Insurance or Surety Bond | Purpose | Cost | |||
| Ins./Surety Bond Line Item 1 | $0.00 | ||||
| Ins./Surety Bond Line Item 2 | $0.00 | ||||
| Ins./Surety Bond Line Item 3 | $0.00 | ||||
| Total Cost (Section J) | $0.00 | ||||
| JUSTIFICATION (Provide a description of how you arrived at the insurance or surety bonds figure with a description and purpose for all planned expenses including the personnel and activities to be covered by the insurance or surety bonds.) | |||||
| [Enter justification text here] | |||||
| K - ADVERTISING & PUBLIC INFORMATION SUB-BUDGET | |||||
| Instructions: Describe total costs for advertising and public information expenses associated with the proposed services. Costs may include materials for community outreach (e.g., design and reproduction costs for pamphlets, newsletters and posters), website hosting, and media campaigns related to the proposed program or service (e.g., print for external purposes, television and radio messaging, billboards). | |||||
| Advertisement or Public Info. Item | Purpose | Cost | |||
| Ad/Public Info. Line Item No. 1 | $0.00 | ||||
| Ad/Public Info. Line Item No. 2 | $0.00 | ||||
| Ad/Public Info. Line Item No. 3 | $0.00 | ||||
| Total Cost (Section K) | $0.00 | ||||
| JUSTIFICATION (Provide a description of how you arrived at the advertising and public information figure with a description and purpose for all planned expenses.) | |||||
| [Enter justification text here] | |||||
| L - CONSUMER/FAMILY REIMBURSEMENT SUB-BUDGET | |||||
| Instructions: Describe total costs for reimbursement of expenses to consumers and members of consumers' families. Expenses (including those paid to vendors or other organizations) must directly support the individual family/client service or treatment plan that addresses mental health or behavioral needs. No cash assistance to individuals or families is permitted. However, grant funds may be used to reimburse individuals or families for reasonable travel expenses, or for payment for services provided to advise programs. This category may also cover fees and reimbursements for consumer participation on committees. (Do not include any costs also reported under in-state travel.) | |||||
| Consumer/Family Reimbursement Item | Purpose | Cost | |||
| Consumer/Family Line Item 1 | $0.00 | ||||
| Consumer/Family Line Item 2 | $0.00 | ||||
| Consumer/Family Line Item 3 | $0.00 | ||||
| Total Cost (Section L) | $0.00 | ||||
| JUSTIFICATION (Provide a description of how you arrived at the consumer/family reimbursement figure with a description and purpose for all planned expenses, including the number of persons you expect to reimburse and the types of expenses you will reimburse such as mileage, lodging, or meals.) | |||||
| [Enter justification text here] | |||||
| M - OTHER COSTS SUB-BUDGET | |||||
| Instructions: List the total of all other costs allocated to the proposed services that cannot be characterized under any other budget category. Include in the text box below a narrative describing any costs included in this category. Copy Section M total cost to the Part 1 line item budget. | |||||
| Describe Item | Purpose | Cost | |||
| Other Costs Line Item No. 1 | $0.00 | ||||
| Other Costs Line Item No. 2 | $0.00 | ||||
| Other Costs Line Item No. 3 | $0.00 | ||||
| Total Cost (Section M) | $0.00 | ||||
| JUSTIFICATION (Provide a description of how you arrived at the "Other" costs with a description and purpose for all planned expenses.) | |||||
| [Enter justification text here] | |||||
| N -- SUBTOTAL DIRECT COST | |||||
| Total Direct Cost is comprised of the sum of total costs from Section A-M. Total Direct Cost figure is listed on the Part 1 line item budget. | |||||
| O -- INDIRECT COST DETAIL | |||||
| Instructions: "Indirect costs" are defined as costs incurred by an agency that are not readily chargeable to a particular program or function, but benefit all agency programs and functions. Costs may relate to overall directing of the organization, record keeping, business management, budgeting and related activities. In determining indirect costs, applicant agencies may follow their federally-approved indirect cost rate. If they do not have such an approved rate, applicants may use an indirect cost rate of up to 10%, as specified under state and federal Allowable Cost Policy. Note: The indirect rate referenced below cannot exceed the agency's federally-approved rate. Use the detailed table below to calculate indirect cost total. Column A: Type in the direct "base cost" amount (often this is the sum of total salary and fringe benefit costs). Column B: Insert indirect cost rate. Column C: Calculates indirect cost amount (Base Cost Amt * Indirect Cost Rate). Applicant agencies using a federally-approved indirect cost rate must attach their indirect cost rate agreement letter with this budget. | |||||
| Direct "Base Cost" Amount | Indirect Cost Rate | Indirect Cost Amount | |||
| $0.00 | 0.000% | $0.00 | |||
| JUSTIFICATION (Provide a description of how you arrived at the Indirect Cost.) | |||||
| [Enter justification text here] |
&LF-01601 (09/2016)&C&"Arial,Bold"&12Line Item Detail Budget: Part 2 &LRFB No. S-0627 DCTS-17&CSchedule 2 - Budget Form &A&R&P of &N &LFORM B - NO FORMULAS&C&"Arial,Bold"Exhibit 2 -- DMHSAS Budget Form: Part 2&R&D &L&Z&F&R&P of &N &LFORM B - NO FORMULAS&C&"Arial,Bold"Exhibit 2 -- DMHSAS Budget Form: Part 2&R&D &L&Z&F&R&P of &N
Exh 2 - Budget Part 3
| Name of Sub-Contractor: | [Enter Contractor here] | ||
| Contract Period: | [Enter Date here] | ||
| General Instructions: Your budget document should be filled out and submitted in Excel. Do not submit a “PDF” Adobe Acrobat copy of your budget document. You have been provided two budget forms. Part 3 (found below) is a summary line item budget and Part 4 is a series of detailed budget tables and explanatory text boxes that document how individual budget line items are derived. Note: Each item requested in the budget can only appear under one Annual Line Item Budget* category. | |||
| Annual Line Item Budget* | Dollar Amt. | Fill Out Detailed Sub-Budget | Additional Detail Required |
| A - SALARY/PERSONNEL COSTS | $0.00 | Go to Part 4 | Provide justification on Part 4 |
| B - FRINGE BENEFIT COSTS | $0.00 | Go to Part 4 | Provide justification on Part 4 |
| C - EQUIPMENT COSTS | $0.00 | Go to Part 4 | Provide justification on Part 4 |
| D - OPERATING EXPENSES | $0.00 | Go to Part 4 | Provide justification on Part 4 |
| E - SUPPLIES | $0.00 | Go to Part 4 | Provide justification on Part 4 |
| F - IN STATE TRAVEL | $0.00 | Go to Part 4 | Provide justification on Part 4 |
| G - OUT-OF-STATE TRAVEL | $0.00 | Go to Part 4 | Provide justification on Part 4 |
| H - CONSULTANT/CONTRACTUAL COSTS | $0.00 | Go to Part 4 | Provide justification on Part 4 |
| I - TRAINING | $0.00 | Go to Part 4 | Provide justification on Part 4 |
| J - INSURANCE & SURETY BONDS | $0.00 | Go to Part 4 | Provide justification on Part 4 |
| K - ADVERTISING & PUBLIC INFORMATION | $0.00 | Go to Part 4 | Provide justification on Part 4 |
| L - CONSUMER/FAMILY REIMBURSEMENT | $0.00 | Go to Part 4 | Provide justification on Part 4 |
| M - OTHER | $0.00 | Go to Part 4 | Provide justification on Part 4 |
| N - SUBTOTAL - DIRECT COSTS (SUM of A-M) | $0.00 | ||
| O - INDIRECT COSTS | $0.00 | Go to Part 4 | Provide justification on Part 4. Attach letter documenting federally approved indirect cost rate. |
| P - TOTAL COSTS (N + O) | $0.00 |
&L&8F-01601 (4/2016)&C&"Arial,Bold"&12Sub-Contractor Summary Line Item Budget: Part 3 &C&"Arial,Bold"&12Exhibit 2 -- DMHSAS Budget Form: Part 3 &C&"Arial,Bold"&12Exhibit 2 -- DMHSAS Budget Form: Part 3
Exh 2 - Budget Part 4
| Name of Contractor: | [Enter Sub-Contractor here] | ||||
| Contract Period: | [Enter Date here] | ||||
| A: SALARY DETAIL SUB-BUDGET | |||||
| Instructions: Use salary detail columns to calculate costs. Column B: Enter title of each position funded by the grant. Column C: Enter either hourly OR monthly rates of pay for grant-funded employee. Column D & E: Enter number of hours per week AND # of weeks, OR # of months, and % FTE per employee. Column F: The following equations are used to calculate salary costs for each line: For hourly positions (“Hourly rate” * “Hours per week” * ”# of weeks”); for monthly positions (“Monthly rate” * ”# of months”). Include only costs covered by this grant proposal or application. Do not include salary costs covered by other funding sources. Pay rates should be reasonable when considering the position titles. Total cost for each position should be calculated based on the length of the contract (e.g., 12-month vs. short-term or late-start contract). Note: Position titles must be consistent with the Work Plan. Copy Section A total cost to the Part 3 line item budget. | |||||
| Position Title (Be Specific) | Hourly Pay Rate | Hours paid per Week | # of weeks paid in contract period | Cost | |
| Hourly Employee Salary Item 1 | $0.00 | 0.00 | 0.00 | $0.00 | |
| Hourly Employee Salary Item 2 | $0.00 | 0.00 | 0.00 | $0.00 | |
| Hourly Employee Salary Item 3 | $0.00 | 0.00 | 0.00 | $0.00 | |
| Hourly Employee Salary Item 4 | $0.00 | 0.00 | 0.00 | $0.00 | |
| Hourly Employee Salary Item 5 | $0.00 | 0.00 | 0.00 | $0.00 | |
| Hourly Employee Salary Item 6 | $0.00 | 0.00 | 0.00 | $0.00 | |
| Hourly Employee Salary Item 7 | $0.00 | 0.00 | 0.00 | $0.00 | |
| Hourly Employee Salary Item 8 | $0.00 | 0.00 | 0.00 | $0.00 | |
| Hourly Employee Salary Item 9 | $0.00 | 0.00 | 0.00 | $0.00 | |
| Position Title (Be Specific) | 1 FTE Monthly Pay Rate | % FTE | # of months paid in contract period | Cost | |
| Monthly Salaried Employee Item 1 | $0.00 | 0.000% | 0.00 | $0.00 | |
| Monthly Salaried Employee Item 2 | $0.00 | 0.000% | 0.00 | $0.00 | |
| Monthly Salaried Employee Item 3 | $0.00 | 0.000% | 0.00 | $0.00 | |
| Monthly Salaried Employee Item 4 | $0.00 | 0.000% | 0.00 | $0.00 | |
| Monthly Salaried Employee Item 5 | $0.00 | 0.000% | 0.00 | $0.00 | |
| Monthly Salaried Employee Item 6 | $0.00 | 0.000% | 0.00 | $0.00 | |
| Monthly Salaried Employee Item 7 | $0.00 | 0.000% | 0.00 | $0.00 | |
| Monthly Salaried Employee Item 8 | $0.00 | 0.000% | 0.00 | $0.00 | |
| Monthly Salaried Employee Item 9 | $0.00 | 0.000% | 0.00 | $0.00 | |
| Total Cost (Section A) | $0.00 | ||||
| JUSTIFICATION (Provide a thorough description of the role and responsibilities of each position.) | |||||
| [Enter justification text here] | |||||
| B: FRINGE BENEFIT DETAIL SUB-BUDGET | |||||
| Instructions: Use fringe benefits detail table to calculate costs. Column B & C: Edit or copy employee titles and salaries from prior table. Column D: Enter total fringe benefit rate for each position. Column E: The following equation is used to calculate costs for each line (Salary * Fringe Rate). Provide a description of the components of the fringe rates in the justification box. Fringe benefit components may include items such as Federal Insurance Contributions Act (FICA) and Unemployment Insurance, Retirement, Life Insurance, Workers Compensation and Health Insurance. Only include costs covered by this proposal or application. Copy Section B total cost to the Part 3 line item budget. | |||||
| Position Title (Be Specific) | Salary | Fringe Rate | Cost | ||
| Fringe Benefit Item 1 | $0.00 | 0.000% | $0.00 | ||
| Fringe Benefit Item 2 | $0.00 | 0.000% | $0.00 | ||
| Fringe Benefit Item 3 | $0.00 | 0.000% | $0.00 | ||
| Fringe Benefit Item 4 | $0.00 | 0.000% | $0.00 | ||
| Fringe Benefit Item 5 | $0.00 | 0.000% | $0.00 | ||
| Fringe Benefit Item 6 | $0.00 | 0.000% | $0.00 | ||
| Fringe Benefit Item 7 | $0.00 | 0.000% | $0.00 | ||
| Fringe Benefit Item 8 | $0.00 | 0.000% | $0.00 | ||
| Fringe Benefit Item 9 | $0.00 | 0.000% | $0.00 | ||
| Fringe Benefit Item 10 | $0.00 | 0.000% | $0.00 | ||
| Fringe Benefit Item 11 | $0.00 | 0.000% | $0.00 | ||
| Fringe Benefit Item 12 | $0.00 | 0.000% | $0.00 | ||
| Fringe Benefit Item 13 | $0.00 | 0.000% | $0.00 | ||
| Fringe Benefit Item 14 | $0.00 | 0.000% | $0.00 | ||
| Fringe Benefit Item 15 | $0.00 | 0.000% | $0.00 | ||
| Fringe Benefit Item 16 | $0.00 | 0.000% | $0.00 | ||
| Fringe Benefit Item 17 | $0.00 | 0.000% | $0.00 | ||
| Fringe Benefit Item 18 | $0.00 | 0.000% | $0.00 | ||
| Total Cost (Section B) | $0.00 | ||||
| JUSTIFICATION (Describe the various components of the fringe rate, and a breakdown of the cost of each component, determined either from an annual agency-wide percentage based on a cost study, or from position-specific fringe rates. ) | |||||
| [Enter justification text here] | |||||
| C: EQUIPMENT PURCHASE DETAIL SUB-BUDGET (Only for items of $5,000 or more) | |||||
| Instructions: Enter data ONLY if you are purchasing a piece of equipment valued at $5,000 or more with grant funds. Use detailed table to calculate total costs. Column B: Enter brief description of each equipment item. Column C: Enter number of units of each item to be purchased. Column D: Enter dollar cost for each item. Column E: The following equation is used to calculate costs for each line (# of units * cost per unit). Equipment is defined as an individual non-expendable tangible personal property item with a value of $5,000 or more and a useful life of more than one year. Applicants must follow the Allowable Cost Policy regarding depreciation of equipment. If items collectively cost more than $5,000 but individually cost less (e.g., three workstations at $2,000 apiece), then the items should be reported under "Supplies," not "Equipment." Copy Section C total cost to the Part 3 line item budget. | |||||
| Description | # of Units | Cost per Unit | Cost | ||
| Equipment Line Item 1 | 0.00 | $0.00 | $0.00 | ||
| Equipment Line Item 2 | 0.00 | $0.00 | $0.00 | ||
| Equipment Line Item 3 | 0.00 | $0.00 | $0.00 | ||
| Total Cost (Section C) | $0.00 | ||||
| JUSTIFICATION (Describe the purpose for each equipment purchase and how the purchase relates to the work plan.) | |||||
| [Enter justification text here] | |||||
| D: OPERATING COSTS | |||||
| Instructions: Operating expenses are non-supply costs directly related to proposed services and includes (but is not limited to) items such as rent, maintenance, printing and reproduction, land telephone and cellular phone services, utilities, IT support specific to the project, and Internet access. Operating costs can be determined either as direct costs or as an allocation of direct costs. If operating costs are determined by an allocation of direct costs, then the same allocation method should be used to estimate operating costs for all programs supported by the agency. Use detailed table to calculate total costs. Copy Section D total cost to the Part 3 line item budget. | |||||
| Description | # of Units | Cost per Unit | Cost | ||
| Operating Cost Line Item 1 | 0.00 | $0.00 | $0.00 | ||
| Operating Cost Line Item 2 | 0.00 | $0.00 | $0.00 | ||
| Operating Cost Line Item 3 | 0.00 | $0.00 | $0.00 | ||
| Total Cost (Section D) | $0.00 | ||||
| JUSTIFICATION (Provide a detailed description of the method used to estimate the operating costs figure, along with a description and the purposes of all items comprising the operating costs total.) | |||||
| [Enter justification text here] | |||||
| E: SUPPLIES PURCHASE DETAIL SUB-BUDGET | |||||
| Instructions: Use detailed table below to calculate costs. Column B: Enter brief description of each supply item or category (such as “laptop computer” or “office paper”). If you are purchasing supply items that cost at least $500 each (such as a laptop computer), then fill out -- Column C: Enter number of units of each item to be purchased. Column D: Enter dollar cost for each item. Column E: The following equation is used to calculate costs for each line (# of units * cost per unit). If you are purchasing supplies that have an item cost less than $500 (such as office paper), then only fill out -- Column E: Total cost of each supply item. Supplies include consumable office supplies (e.g., postage, paper, pens, desk phones) and any item priced less than $5,000 (e.g., laptops, printers, cell phones) that will be used for purposes under the proposal or application. Items in this category may also include start-up supplies such as office desks, chairs and file cabinets, and program-specific supplies like Urine Assessment kits, medications and printed curricula or materials for clients (e.g., family psycho-educational materials). Copy Section E total cost to the Part 3 line item budget. | |||||
| Description | # of Units | Cost per Unit | Cost | ||
| Supply Item 1 | 0.00 | $0.00 | $0.00 | ||
| Supply Item 2 | 0.00 | $0.00 | $0.00 | ||
| Supply Item 3 | 0.00 | $0.00 | $0.00 | ||
| Supply Item 4 | 0.00 | $0.00 | $0.00 | ||
| Supply Item 5 | 0.00 | $0.00 | $0.00 | ||
| Total Cost (Section E) | $0.00 | ||||
| JUSTIFICATION (Please describe the purpose for any supply purchase with a total cost of $500 or greater, and how each item will be used for this program.) | |||||
| [Enter justification text here] | |||||
| F: IN-STATE TRAVEL DETAIL SUB-BUDGET | |||||
| Instructions: Use detailed table below to calculate costs. Mileage: Enter mileage, enter number of miles, multiply rate by number of miles to derive cost. Meals: Enter daily meal rate cost and number of days. Lodging: Enter nightly lodging cost & number of nights of lodging. Other: Enter description and total of any other in-state travel costs. Applicant must use the state-approved rates, unless the applicant's board approves use of a higher rate and that rate applies to all agency programs. Rates for mileage cannot exceed current federal General Services Administration privately-owned vehicle rate (See http://www.gsa.gov/portal/content/100715 for updates on federal rate), or exceed allowed federal per diem and lodging rates (See http://www.gsa.gov/portal/category/100000). Reimbursement must be related to grant-funded activities for staff, volunteers or clients, such as site visits or training. Copy Section F total cost to the Part 3 line item budget. | |||||
| Mileage Rate | # of Miles | Cost | |||
| Mileage Reimbursement | $0.000 | 0 | $0.00 | ||
| Daily Rate | # of Days | Cost | |||
| Meal Reimbursement | $0.00 | 0 | $0.00 | ||
| Nightly Lodging rate | # of nights | Cost | |||
| Lodging Reimbursement | $0.00 | 0 | $0.00 | ||
| Describe Cost: | Cost | ||||
| Other In-State Travel Costs | [Enter description here] | $0.00 | |||
| Total Cost (Section F) | $0.00 | ||||
| JUSTIFICATION (Please provide a detailed description of how you arrived at the amounts provided above. List the number of trips, the purpose of the travel and destinations, and describe which staff positions will be traveling.) | |||||
| [Enter justification text here] | |||||
| G: OUT-OF-STATE TRAVEL DETAIL SUB-BUDGET | |||||
| Instructions: Use detailed table below to calculate costs. See instructions in Section F above for IN-STATE TRAVEL. Applicant must use the state-approved rates, unless the applicant board approves a higher rate and that rate applies to all agency programs. Rates for mileage cannot exceed current federal General Services Administration privately-owned vehicle rate, or exceed federally-allowable meal, lodging and airfare rates. (See http://www.gsa.gov/portal/content/100715 for updates on federal travel rate. See also http://www.gsa.gov/portal/content/104877 for other federally-allowed rates, and http://oser.state.wi.us/bulletins/bulletin_get.asp?bid=604 for list of 'high cost cities' for lodging). Reimbursement must be related to grant-funded activities for staff, volunteers or clients such as site visits or training. Copy Section G total cost to the Part 3 line item budget. | |||||
| Type Cost | Cost Amount | ||||
| Airfare cost | $0.00 | ||||
| Meal Cost | $0.00 | ||||
| Lodging Cost | $0.00 | ||||
| Other Cost | $0.00 | ||||
| Total Cost (Section G) | $0.00 | ||||
| JUSTIFICATION (Please provide a detailed description of how you arrived at the amounts provided above. List the number of trips, type of travel, rate per trip, the purpose of the travel and destinations, and describe which staff positions will be traveling.) | |||||
| [Enter justification text here] | |||||
| H: CONSULTANT & CONTRACTUAL DETAIL SUB-BUDGET | |||||
| Instructions: Use detailed table below to list total costs. List in the upper section the total budget cost for contractors/consultants who are individuals or self-employed. List in the lower section total budget cost for agency or organization sub-contractors. If any consultant or contractual service supports both this funded program and programs from other funding sources, develop a reasonable cost allocation method and keep it available for review upon request. Copy Section H total cost to the Part 3 line item budget. | |||||
| Name of Consultant/Contractor | Description of Service | Cost | |||
| Individual Consultant/Contractor #1 | $0.00 | ||||
| Individual Consultant/Contractor #2 | $0.00 | ||||
| Individual Consultant/Contractor #3 | $0.00 | ||||
| Name of Contractor | Description of Service | Cost | |||
| Agency Contractor #1 | $0.00 | ||||
| Agency Contractor #2 | $0.00 | ||||
| Agency Contractor #3 | $0.00 | ||||
| Total Cost (Section H) | $0.00 | ||||
| JUSTIFICATION (Please provide a detailed description of how you arrived at the amounts listed above. Also describe the method used to calculate the amount needed. [Examples may include unit cost and anticipated time or units, hourly rate, or daily rate.] Note the programming, services or products each contractor/consultant will provide.) | |||||
| [Enter justification text here] | |||||
| I - TRAINING SUB-BUDGET | |||||
| Instructions: Describe total training costs for proposed funded staff, volunteers associated with the proposal or application, and proposed clients. This category may include training costs for staff funded by this grant, volunteers associated with proposal, and clients of the program. (Note: Training costs covered under Section H cannot also be covered under Section I.) Costs may also include registration fees, speaker fees and costs, meeting rooms, training materials and other supplies, and attendance at program-related conferences. Copy Section I total cost to the Part 3 line item budget. | |||||
| Describe Training Event and/or Trainers | Purpose of Training | Cost per Unit | Cost | ||
| Training Cost Line Item 1 | $0.00 | $0.00 | |||
| Training Cost Line Item 2 | $0.00 | $0.00 | |||
| Training Cost Line Item 3 | $0.00 | $0.00 | |||
| Total Cost (Section I) | $0.00 | ||||
| JUSTIFICATION (Describe how you arrived at the training cost figure with a description and purpose for all planned training expenditures including the number of persons to receive training. Training costs must align with the program work plan.) | |||||
| [Enter justification text here] | |||||
| J - INSURANCE & SURETY BONDS SUB-BUDGET | |||||
| Instructions: Describe total costs for insurance and surety bonds needed for the proposed services. Costs may include, but are not limited to, liability insurance, auto insurance, property insurance to cover staff while driving, property insurance covering the building or facility, insurance for program directors or officers, and cost of surety bonds. Copy Section J total cost to the Part 3 line item budget. | |||||
| Name of Insurance or Surety Bond | Purpose | Cost | |||
| Ins./Surety Bond Line Item 1 | $0.00 | ||||
| Ins./Surety Bond Line Item 2 | $0.00 | ||||
| Ins./Surety Bond Line Item 3 | $0.00 | ||||
| Total Cost (Section J) | $0.00 | ||||
| JUSTIFICATION (Provide a description of how you arrived at the insurance or surety bonds figure with a description and purpose for all planned expenses including the personnel and activities to be covered by the insurance or surety bonds.) | |||||
| [Enter justification text here] | |||||
| K - ADVERTISING & PUBLIC INFORMATION SUB-BUDGET | |||||
| Instructions: Describe total costs for advertising and public information expenses associated with the proposed services. Costs may include materials for community outreach (e.g., design and reproduction costs for pamphlets, newsletters and posters), website hosting, and media campaigns related to the proposed program or service (e.g., print for external purposes, television and radio messaging, billboards). Copy Section K total cost to the Part 3 line item budget. | |||||
| Advertisement or Public Info. Item | Purpose | Cost | |||
| Ad/Public Info. Line Item No. 1 | $0.00 | ||||
| Ad/Public Info. Line Item No. 2 | $0.00 | ||||
| Ad/Public Info. Line Item No. 3 | $0.00 | ||||
| Total Cost (Section K) | $0.00 | ||||
| JUSTIFICATION (Provide a description of how you arrived at the advertising and public information figure with a description and purpose for all planned expenses.) | |||||
| [Enter justification text here] | |||||
| L - CONSUMER/FAMILY REIMBURSEMENT SUB-BUDGET | |||||
| Instructions: Describe total costs for reimbursement of expenses to consumers and members of consumers' families. Expenses (including those paid to vendors or other organizations) must directly support the individual family/client service or treatment plan that addresses mental health or behavioral needs. No cash assistance to individuals or families is permitted. However, grant funds may be used to reimburse individuals or families for reasonable travel expenses, or for payment for services provided to advise programs. This category may also cover fees and reimbursements for consumer participation on committees. (Do not include any costs also reported under in-state travel.) Copy Section L total cost to the Part 3 line item budget. | |||||
| Consumer/Family Reimbursement Item | Purpose | Cost per Item | Cost | ||
| Consumer/Family Line Item 1 | $0.00 | $0.00 | |||
| Consumer/Family Line Item 2 | $0.00 | $0.00 | |||
| Consumer/Family Line Item 3 | $0.00 | $0.00 | |||
| Total Cost (Section L) | $0.00 | ||||
| JUSTIFICATION (Provide a description of how you arrived at the consumer/family reimbursement figure with a description and purpose for all planned expenses, including the number of persons you expect to reimburse and the types of expenses you will reimburse such as mileage, lodging, or meals.) | |||||
| [Enter justification text here] | |||||
| M - OTHER COSTS SUB-BUDGET | |||||
| Instructions: List the total of all other costs allocated to the proposed services that cannot be characterized under any other budget category. Include in the text box below a narrative describing any costs included in this category. Copy Section M total cost to the Part 3 line item budget. | |||||
| Describe Item | Purpose | Cost | |||
| Other Costs Line Item No. 1 | $0.00 | ||||
| Other Costs Line Item No. 2 | $0.00 | ||||
| Other Costs Line Item No. 3 | $0.00 | ||||
| Total Cost (Section M) | $0.00 | ||||
| JUSTIFICATION (Provide a description of how you arrived at the "Other" costs with a description and purpose for all planned expenses.) | |||||
| [Enter justification text here] | |||||
| N -- TOTAL DIRECT COST | |||||
| Total Direct Cost is comprised of the sum of total costs from Section A-M. Total Direct Cost figure is listed on the Part 3 line item budget. | |||||
| O -- INDIRECT COST DETAIL | |||||
| Instructions: "Indirect costs" are defined as costs incurred by an agency that are not readily chargeable to a particular program or function, but benefit all agency programs and functions. Costs may relate to overall directing of the organization, record keeping, business management, budgeting and related activities. In determining indirect costs, applicant agencies may follow their federally-approved indirect cost rate. If they do not have such an approved rate, applicants may use an indirect cost rate of up to 10%, as specified under state and federal Allowable Cost Policy. Note: The indirect rate referenced below cannot exceed the agency's federally-approved rate. Use the detailed table below to calculate indirect cost total. Column A: List direct "base cost" amount (normally the sum of total salary and fringe benefit costs). Column B: Insert indirect cost rate. Column C: Calculate indirect cost amount (Base Cost Amt * Indirect Cost Rate). Copy Indirect Cost Amount to the Part 3 line item budget. Applicant agencies using a federally-approved indirect cost rate may attach their indirect cost rate agreement letter with this budget. | |||||
| Direct "Base Cost" Amount | Indirect Cost Rate | Indirect Cost Amount | |||
| $0.00 | 0.000% | $0.00 | |||
| JUSTIFICATION (Provide a description of how you arrived at the Indirect Cost.) | |||||
| [Enter justification text here] |
&L&9F-06101 (4/2016)&C&"Arial,Bold"&11Sub-Contractor Line Item Detail Budget: Part 4 &C&"Arial,Bold"&12Exhibit 2 --- DMHSAS Budget Form: Part 4 &C&"Arial,Bold"&12Exhibit 2 --- DMHSAS Budget Form: Part 4
Part 3-Subcontr summary
| Name of Organization: | [Enter Sub-Contractor here] | ||
| Contract Period: | [Enter Date here] | ||
| General Instructions: Your budget document must be filled out and submitted in Excel. Do not submit a “PDF” Adobe Acrobat copy of your budget document. You have been provided two budget forms. Part 1 (found below) is a summary line item budget and Part 2 is a series of detailed budget tables and explanatory text boxes that document how individual budget line items are derived. Note: Each item requested in the budget can only appear under one Annual Line Item Budget category. | |||
| Annual Line Item Budget | Dollar Amt. | Fill Out Detailed Sub-Budget | Additional Detail Required |
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