18E Form 3A - edits

OMB No.: 0915-0285 Expiration Date: XX/XX/20XX

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration FORM 3A: LOOK-ALIKE BUDGET INFORMATION				FOR HRSA USE ONLY
				LAL Number		Application Tracking Number
Note: The program income total on this form must match the program income total on Form 3.
Budget Category	Community Health Centers (CHC - 330(e))	Migrant Health Centers (MHC - 330(g))	Health Care for the Homeless (HCH - 330(h))		Public Housing Primary Care (PHPC - 330(i))		Total will auto-calculate in EHB
Expenses
Personnel
Fringe Benefits
Travel
Equipment
Supplies
Contractual
Construction
Other
Total Direct Charges (sum of a through h) will auto-calculate in EHB
Indirect Charges
Total Expenses (sum of i and j)  will auto-calculate in EHB
Revenue
Applicant
Federal
State
Local
Other
Program Income
Total Revenue (sum of a through f)  will auto-calculate in EHB

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. . paperwork@hrsa.gov HYPERLINK "https://sharepoint.hrsa.gov/sites/bphc/oppd/ED1/OMB%20Forms%20Approval%202020/paperwork@hrsa.gov" 42 U.S.C. 254b HYPERLINK "http://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section254b&num=0&edition=prelim"