MAI Program Budget Form by HC120705065047

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									                                                                                           MAI Document Checklist

Contractor and Contract Number                                                                              Fiscal Year
                                                                                                             2012-2013



                                                                                                       Office of AIDS
    Check Off                              Documents Required for All Contractors
                                                                                                         Use Only
                  Document Checklist

                  Non-Personnel Description / Justification / Explanation

                  Contractor Fiscal and Service Provider Location List

                  Sub-Contractor Fiscal and Service Provider Location List

                  MAI Contractor Contact Information

                  Five Line Item Budgets for Year 3

                  Budget Overview

                  FORM A - MAI Contractor Administrative Budget Summary

                  FORM B - MAI Contractor Administrative Personnel Detail
                  Note: Form C is not applicable to MAI, only to HCP

                  In alphabetical order, attach the following for each Service Provider:

                       FORM D - MAI Client Service Provider Budget Summary

                       FORM E - MAI Client Service Provider Personnel Detail

                       FORM F - MAI Service Provider SubContractor
                                                         MAI Non-Personnel Justification

DUNS #                                                                                    Fiscal Year
Contractor and                                                                                2012-2013
Contract Number


                             Description of Non-Personnel Expenses
If non-personnel costs are being funded for Client Services, describe how the non-personnel
expenses will be utilized.
      Services                                         Description
                                                                        MAI Contractor Agency Locations List

                                     Contractor and Contract Number                                                         Fiscal Year
                                                                                                                             2012-2013



                                                                                                                      Office of AIDS
   Contractor Agency Name(s)                              Address Location (Street, City, Zip)
                                                                                                                        Use Only

If MAI-funded client services are provided at sites other than the one listed in the Service Provider Information box, please complete a
row for each site.

         Ex: Agency XYZ              Address Location 1

                                     Address Location 2

                                     Address Location 3
                                                                                            MAI Sub-Agency Locations List

                                              Contractor and Contract Number                                                        Fiscal Year
                                                                                                                                     2012-2013



                                                                                                                              Office of AIDS
     Subcontracted Agency Name(s)                                  Address Location (Street, City, Zip)
                                                                                                                                Use Only
List all Subcontracted Service Provider Agency Locations. If Subcontractors is a fiscal intermediary only, list all Sub-Subcontracted Agency and
                 Locations. This information is required for scheduling annual site visits and completing the annual HRSA RSR.

              Ex: Agency XYZ                  Address Location 1

                                              Address Location 2

                                              Address Location 3
                                                                                    MAI Contractor Contact Information

Contractor, Contract Number, and DUNS #                                                                                             Fiscal Year
                                                                                                                                     2012-2013


                                                             Agency Information

Website Address (if any)




                                                              Program Contact
The Program Contract is the primary Contractor staff member responsible for program planning, policy matters, progress reports, and
contract monitoring, etc.

First and Last Name                                                                             Title


Mailing Address                                                                                 Telephone Number


E-Mail Address                                                                                  Fax Number




                                                              Invoicing Contact
The Invoicing Contact is the primary Contractor staff member responsible for invoicing, budgets revisions, etc. If this person is the same as
the Program Contact enter "Same as above" in the First and Last Name box below.

First and Last Name                                                                             Title


Mailing Address                                                                                 Telephone Number


E-Mail Address                                                                                  Fax Number
                                                          MAI Five Line Item Budget

Contractor and Contract Number



Year 3 Fiscal Year 2012-2013

                                Form A           Form D                Form D
                             Contractor      Contractor's MAI   Subcontractor's MAI
                            Administrative   Service Provider      Service Provider
                               Costs         Budget Summary        Budget Summary             Total
                                              (if applicable)    (if applicable, and if
                                                                so, Other Costs only)

1.   Personnel                                                                            $           -
2.   Operating Expenses                                                                   $           -
3.   Capital Expenditures                                                                 $           -
4.   Other Costs                                                                          $           -
5.   Indirect Costs                                                                       $           -
        Total Budget        $          -     $            -     $                 -       $           -
                                                                                                    MAI Budget Overview

Contractor and Contract Number                                                                                      Fiscal Year
                                                                                                                    2012-2013



                                 Contractor Administrative Costs                                           Amount

Contractor Administrative Costs (not to exceed 10% of total allocation)                                        $0    #DIV/0!
                                MAI Client Service Provider Costs
   (Enter individual Service Providers on separate lines below, whether provided by contractor or
                                       subcontracted agency.
            A FORM D and FORM E must be completed for each service provider listed.)




                                       Total MAI Allocation                                                                 $0
                                      FORM A - MAI Contractor Administrative Budget Summary

Contractor and Contract Number                                                                                                     Fiscal Year
                                                                                                                                    2012-2013


                                                   Contractor Information

Contact Person                                                     Title



Mailing Address                                                    Telephone Number



E-Mail Address                                                     Fax Number


Do members of minority racial/ethnic groups constitute a majority
of Board members and/or a majority of staff (volunteer or paid)   Ownership Status (Check One)
providing care? (Check one)                                          Public/Local   Public/State                  Public/Federal

                       Yes     No                                       Private/Non-Profit   Private/For Profit   Incorporated




  Expenses Category                                    Description                                                      Budgeted Amount

      Admin Personnel                                                Total Administrative Personnel

   Operating Expenses




                                                                            Total Operating Expenses                                       $0
   Capital Expenditures


                                                                           Total Capital Expenditures                                      $0

          Indirect Costs




                                                                                      Total Indirect Costs                                 $0
                                                        Cannot exceed 15% of Total Administrative Personnel                           #DIV/0!

                                                           Total Contractor Administrative Budget                                          $0
                                                           (cannot exceed 10% of total Contractor allocation)
                                                                                                                                      #DIV/0!
                                                               FORM B - MAI Contractor Administrative Personnel Detail

Contractor and Contract Number                                                                                                                          Fiscal Year

                                                                                                                                                           2012-13

                    Position Title                            Staff Member's First and Last Name               If vacant, what is the estimated hire date?




                                                                                                                                           Salary paid by this
  Describe Duties (include purpose and destination of any job-related travel)    Total Annual Salary             Total FTE
                                                                                                                                                contract



                                                                                If Travel is Required,
                                                                                   Estimated Travel               Benefits              Total Travel and Benefits
                                                                                       Expense
                                                                                                                     $0                            $0

                                                                                                                             Subtotal              $0


                    Position Title                            Staff Member's First and Last Name               If vacant, what is the estimated hire date?




                                                                                                                                           Salary paid by this
  Describe Duties (include purpose and destination of any job-related travel)    Total Annual Salary             Total FTE
                                                                                                                                                contract



                                                                                If Travel is Required,
                                                                                   Estimated Travel               Benefits              Total Travel and Benefits
                                                                                       Expense
                                                                                                                                                   $0

                                                                                                                             Subtotal              $0


                    Position Title                            Staff Member's First and Last Name               If vacant, what is the estimated hire date?




                                                                                                                                           Salary paid by this
  Describe Duties (include purpose and destination of any job-related travel)    Total Annual Salary             Total FTE
                                                                                                                                                contract



                                                                                If Travel is Required,
                                                                                   Estimated Travel               Benefits              Total Travel and Benefits
                                                                                       Expense
                                                                                                                                                   $0

                                                                                                                             Subtotal              $0


                    Position Title                            Staff Member's First and Last Name               If vacant, what is the estimated hire date?




                                                                                                                                           Salary paid by this
  Describe Duties (include purpose and destination of any job-related travel)    Total Annual Salary             Total FTE
                                                                                                                                                contract



                                                                                If Travel is Required,
                                                                                   Estimated Travel               Benefits              Total Travel and Benefits
                                                                                       Expense
                                                                                                                                                   $0

                                                                                                                             Subtotal              $0

                                                                                                         Total Personnel (this page)               $0
                                                           FORM D - MAI Client Service Provider Budget Summary

Contractor and Contract Number                                                                                                                                                   Fiscal Year
                                                                                                                                                                                  2012-2013

                                                                 Service Provider Information

Service Provider Name                                                                                  Bid Status (Check One)

                                                                                                           Sole Source (Attach Justification)            Competitive Bid

Contact Person                                                                                         Title



Mailing Address                                                                                        Telephone Number



E-Mail Address                                                                                         Fax Number



Website Address (if any)                                                                               Federal Taxpayer Identification Number



Do members of minority racial/ethnic groups constitute a majority of Board members
                                                                                                       Ownership Status (Check One)
and/or a majority of staff (volunteer or paid) providing care? (Check one)
                                                                                                          Public/Local              Public/State                Public/Federal
                                                                             Yes             No           Private/Non-Profit        Private/For Profit          Incorporated




                                        Client Service Costs

                                                                                                         Estimated Clients Served                               Budgeted Amount
                  Services
 NOTE: The MAI service categories must be used    Personnel Costs        Non-Personnel Costs
           here. Use drop down list

                                                                                                                                                                                         $0

                                                                                                                                                                                         $0

                                                                                                                                                                                         $0

                                                                                                                                                                                         $0

                                                                                                                                                                                         $0

                                                                                                                                                                                         $0

                                                                                                                                                                                         $0

                                        Totals                      $0                            $0                           Total Services                                            $0

                 Administrative Personnel                                                          Total Administrative Personnel

                       Operating Expenses




                                                                                                          Total Operating Expenses                                                       $0

                      Capital Expenditures


                                                                                                          Total Capital Expenditures                                                     $0

                               Indirect Costs




                                                                                                                     Total Indirect Costs
                                                               (cannot exceed 15% of Client Service Provider Total Personnel Expenses)
                                                                                                                                                                                         $0

                                                                                                          Total Administrative Costs                                                     $0
                                                                         (cannot exceed 10% of the Client Service Provider total budget)
                                                                                                                                                                                    #DIV/0!
                                                                                                       Total Service Provider Budget                                                     $0
                                                    FORM E - MAI Client Service Provider Personnel Detail
Contractor and Contract Number                                                                                                                   Fiscal Year
                                                                                                                                                  2012-2013
                                                        Service Provider Information
Service Provider Name                                               Contact Name and Title

Mailing Address                                                         Telephone Number

E-Mail Address                                                          Fax Number

                                                                                                     If vacant, what is
                                                                                                                            Is this an administrative
             Position Title                      Staff Member's First and Last Name                     the estimated
                                                                                                                                    position?
                                                                                                          hire date?
                                                                                                                                          Yes         No

 Describe Duties (include purpose and destination of any job-                                                                  Salary paid by this
                                                                         Total Annual Salary              Total FTE
                          related travel)                                                                                           contract
To perform Services that link and transition selective HIV - Infected
    individuals between HIV testing and early prevention care,               Is this position also funded to provide:         HCP Outreach Services
                 treatment and prevention services                                    (Check all that apply)                 HCP Early Intervention Services
                                                                                                                             State-Funded HIV Prevention

                                                                        If Travel is Required,
                                                                           Estimated Travel               Benefits          Total Travel and Benefits
                                                                               Expense


MAI Service Category                                                                                             Subtotal                   $0
                                                                                                     If vacant, what is
                                                                                                                            Is this an administrative
             Position Title                      Staff Member's First and Last Name                     the estimated
                                                                                                                                    position?
                                                                                                          hire date?
                                                                                                                                          Yes         No

 Describe Duties (include purpose and destination of any job-                                                                  Salary paid by this
                                                                         Total Annual Salary              Total FTE
                        related travel)                                                                                             contract

                                                                                                                              HCP Outreach Services
                                                                             Is this position also funded to provide:
                                                                                                                             HCP Early Intervention Services
                                                                                      (Check all that apply)
                                                                                                                             State-Funded HIV Prevention

                                                                        If Travel is Required,
                                                                           Estimated Travel               Benefits          Total Travel and Benefits
                                                                               Expense
                                                                                                                                            $0
MAI Service Category                                                                                             Subtotal                   $0
                                                                                                     If vacant, what is
                                                                                                                            Is this an administrative
             Position Title                      Staff Member's First and Last Name                     the estimated
                                                                                                                                    position?
                                                                                                          hire date?
                                                                                                                                          Yes         No

 Describe Duties (include purpose and destination of any job-                                                                  Salary paid by this
                                                                         Total Annual Salary              Total FTE
                        related travel)                                                                                             contract

                                                                                                                              HCP Outreach Services
                                                                             Is this position also funded to provide:
                                                                                                                             HCP Early Intervention Services
                                                                                      (Check all that apply)
                                                                                                                             State-Funded HIV Prevention

                                                                        If Travel is Required,
                                                                           Estimated Travel               Benefits          Total Travel and Benefits
                                                                               Expense
                                                                                                                                            $0
MAI Service Category                                                                                             Subtotal                   $0
                                                                                             If vacant, what is
                                                                                                                    Is this an administrative
            Position Title                  Staff Member's First and Last Name                  the estimated
                                                                                                                            position?
                                                                                                  hire date?
                                                                                                                                  Yes         No


 Describe Duties (include purpose and destination of any job-                                                          Salary paid by this
                                                                Total Annual Salary               Total FTE
                        related travel)                                                                                     contract

                                                                                                                      HCP Outreach Services
                                                                     Is this position also funded to provide:
                                                                                                                     HCP Early Intervention Services
                                                                              (Check all that apply)
                                                                                                                     State-Funded HIV Prevention


                                                                If Travel is Required,
                                                                   Estimated Travel               Benefits          Total Travel and Benefits
                                                                       Expense
                                                                                                                                    $0
MAI Service Category                                                                                     Subtotal                   $0

                                                                               Total Personnel (this page)                          $0
                                           FORM F -MAI Client Service Provider Subcontractor

Contractor and Contract Number                                                       DUNS #                                     Fiscal Year
                                                                                                                                 2012-2013

Note: Subcontracted Service Providers who utilize subcontracts to fund other entities to provide MAI services Must Complete
this form for each entity.

                                                              Service Provider Information

Service Provider Name



Contact Person                                                                       Title



Mailing Address                                                                      Telephone Number



E-Mail Address                                                                       Fax Number



Website Address (if any)                                                             Federal Taxpayer Identification Number




                          Client Service Costs

                                                                                       Estimated Clients Served       Budgeted Amount
                                   Services
NOTE: The exact HRSA category name(s) for allowable Tier One and Tier Two services
                              must be used here.


                                                                                                                                        $0

                                                                                                                                        $0

                                                                                                                                        $0

                                                                                                                                        $0

                                                                                                                                        $0

                                                                                                                                        $0

                                                                                                                                        $0

                                                                                                   Total Services                       $0

								
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