Budget Detail Worksheet RHSD Sample

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					                                                                                                           Appendix G
                                                BUDGET DETAIL WORKSHEET

                         RURAL HEALTH SERVICES DEVELOPMENT (RHSD) PROGRAM
                                         COMPLETE ONLY THE AREAS HIGHLIGHTED IN YELLOW

CORPORATION NAME:                                     COMBINED RHSD CLINICS          GRANT NUMBER:
Central Valley Health Services, Inc.                                                    09-XXXXX


    X       FISCAL YEAR 2009-10

1. PERSONNEL SERVICES
                                                                       % FTE (RHSD
                                                                                       FULL TIME ANNUAL      COSTS PAID BY THIS
                               CLASSIFICATION TITLE                    PROGRAMS
                                                                          ONLY)       SALARIES OR WAGES           GRANT

Physician                                                                     0.50           $120,000.00             $60,000.00

Medical Assistant                                                             0.50             24,000.00                12,000.00

Dentist                                                                       0.25            110,000.00                27,500.00

Health Educators (1) and (2)                                                  1.10 29,000 to 38,000                     40,900.00




   TOTAL SALARIES AND WAGES                                                                                        $140,400.00
   FRINGE BENEFITS (NOT TO EXCEED 32% OF TOTAL SALARIES AND WAGES)                         19.13%                    $26,865.00

TOTAL PERSONNEL COST (ITEM 1)                                                                                     $167,265.00


2. OPERATING EXPENSES (e.g. travel, per diem, office supplies, rent)




TOTAL OPERATING EXPENSES (ITEM 2)                                                                                         $0.00


3. OTHER COSTS (e.g. subcontracts, educational materials)
Curriculum, Surveys                                                                                                     $2,750.00

Pedometers                                                                                                                400.00



TOTAL OTHER COSTS (ITEM 3)                                                                                          $3,150.00


4. INDIRECT COST (Not to exceed 10% of Total Salaries and Wages, Excluding Fringe Benefits)
TOTAL INDIRECT COST (ITEM 4)                                                              10.00%                   $14,040.00


TOTAL BUDGET (SUM OF LINE ITEMS 1 THRU 4)                                                                      $184,455.00
                                                                                                             Attachment 8
                                            BUDGET DETAIL WORKSHEET


                        RURAL HEALTH SERVICES DEVELOPMENT (RHSD) PROGRAM
                                         COMPLETE ONLY THE AREAS HIGHLIGHTED IN YELLOW
CORPORATION NAME:                                 CLINIC NAME:                         GRANT NUMBER:
Central Valley Health Services, Inc.              Madera Medical and Dental Clinic         09-XXXXX

    X       FISCAL YEAR 2009-10                   FISCAL YEAR 2010-11                  FISCAL YEAR 2011-12


1. PERSONNEL SERVICES
                                                                         % FTE (RHSD
                                                                                         FULL TIME ANNUAL      COSTS PAID BY THIS
                           CLASSIFICATION TITLE                          PROGRAMS
                                                                            ONLY)       SALARIES OR WAGES           GRANT

Physician                                                                       0.50           $120,000.00             $60,000.00
Medical Assistant                                                               0.50             24,000.00               12,000.00
Dentist                                                                         0.25            110,000.00               27,500.00

                                                                                                                              0.00

                                                                                                                              0.00

                                                                                                                              0.00

                                                                                                                              0.00

                                                                                                                              0.00

                                                                                                                              0.00

                                                                                                                              0.00
   TOTAL SALARIES AND WAGES                                                                                           $99,500.00
   FRINGE BENEFITS (NOT TO EXCEED 32% OF TOTAL SALARIES AND WAGES)                           27.00%                    $26,865.00
TOTAL PERSONNEL COST (ITEM 1)                                                                                       $126,365.00

2. OPERATING EXPENSES (e.g. travel, per diem, office supplies, rent)




TOTAL OPERATING EXPENSES (ITEM 2)                                                                                           $0.00


3. OTHER COSTS (e.g. subcontracts, educational materials)




TOTAL OTHER COSTS (ITEM 3)                                                                                                  $0.00

4. INDIRECT COST (Not to exceed 10% of Total Salaries and Wages, Excluding Fringe Benefits)
TOTAL INDIRECT COST (ITEM 4)                                                                 10.00%                   $9,950.00


TOTAL BUDGET (SUM OF LINE ITEMS 1 THRU 4)                                                                        $136,315.00
                                                                                                           Attachment 8
                                          BUDGET DETAIL WORKSHEET


                      RURAL HEALTH SERVICES DEVELOPMENT (RHSD) PROGRAM
                                       COMPLETE ONLY THE AREAS HIGHLIGHTED IN YELLOW
CORPORATION NAME:                               CLINIC NAME:                         GRANT NUMBER:
Central Valley Health Services, Inc.            Chowchilla Family Health Center          09-XXXXX

    X     FISCAL YEAR 2009-10                   FISCAL YEAR 2010-11                  FISCAL YEAR 2011-12


1. PERSONNEL SERVICES
                                                                       % FTE (RHSD
                                                                                       FULL TIME ANNUAL      COSTS PAID BY THIS
                         CLASSIFICATION TITLE                          PROGRAMS
                                                                          ONLY)       SALARIES OR WAGES           GRANT

Health Educator (1)                                                           1.00            $38,000.00             $38,000.00
Health Educator (2)                                                           0.10             29,000.00                  2,900.00

                                                                                                                              0.00

                                                                                                                              0.00

                                                                                                                              0.00

                                                                                                                              0.00

                                                                                                                              0.00

                                                                                                                              0.00

                                                                                                                              0.00

                                                                                                                              0.00
   TOTAL SALARIES AND WAGES                                                                                         $40,900.00
   FRINGE BENEFITS (NOT TO EXCEED 32% OF TOTAL SALARIES AND WAGES)                          0.00%                           $0.00
TOTAL PERSONNEL COST (ITEM 1)                                                                                      $40,900.00

2. OPERATING EXPENSES (e.g. travel, per diem, office supplies, rent)




TOTAL OPERATING EXPENSES (ITEM 2)                                                                                          $0.00


3. OTHER COSTS (e.g. subcontracts, educational materials)
Curriculum, Surveys                                                                                                    $2,750.00

Pedometers                                                                                                                 400.00



TOTAL OTHER COSTS (ITEM 3)                                                                                          $3,150.00

4. INDIRECT COST (Not to exceed 10% of Total Salaries and Wages, Excluding Fringe Benefits)
TOTAL INDIRECT COST (ITEM 4)                                                               10.00%                   $4,090.00


TOTAL BUDGET (SUM OF LINE ITEMS 1 THRU 4)                                                                        $48,140.00
                                                                                                           Attachment 8
                                          BUDGET DETAIL WORKSHEET


                      RURAL HEALTH SERVICES DEVELOPMENT (RHSD) PROGRAM
                                       COMPLETE ONLY THE AREAS HIGHLIGHTED IN YELLOW
CORPORATION NAME:                               CLINIC NAME:                         GRANT NUMBER:
                                                                                         09-XXXXX

   X     FISCAL YEAR 2009-10                    FISCAL YEAR 2010-11                  FISCAL YEAR 2011-12


1. PERSONNEL SERVICES
                                                                       % FTE (RHSD
                                                                                       FULL TIME ANNUAL      COSTS PAID BY THIS
                         CLASSIFICATION TITLE                          PROGRAMS
                                                                          ONLY)       SALARIES OR WAGES           GRANT

                                                                                                                           $0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00
   TOTAL SALARIES AND WAGES                                                                                                $0.00
  FRINGE BENEFITS (NOT TO EXCEED 32% OF TOTAL SALARIES AND WAGES)                           0.00%
TOTAL PERSONNEL COST (ITEM 1)                                                                                             $0.00

2. OPERATING EXPENSES (e.g. travel, per diem, office supplies, rent)




TOTAL OPERATING EXPENSES (ITEM 2)                                                                                         $0.00


3. OTHER COSTS (e.g. subcontracts, educational materials)




TOTAL OTHER COSTS (ITEM 3)                                                                                                $0.00

4. INDIRECT COST (Not to exceed 10% of Total Salaries and Wages, Excluding Fringe Benefits)
TOTAL INDIRECT COST (ITEM 4)                                                               0.00%


TOTAL BUDGET (SUM OF LINE ITEMS 1 THRU 4)                                                                                 $0.00
                                                                                                           Attachment 8
                                          BUDGET DETAIL WORKSHEET


                      RURAL HEALTH SERVICES DEVELOPMENT (RHSD) PROGRAM
                                       COMPLETE ONLY THE AREAS HIGHLIGHTED IN YELLOW
CORPORATION NAME:                               CLINIC NAME:                         GRANT NUMBER:
                                                                                         09-XXXXX

   X     FISCAL YEAR 2009-10                    FISCAL YEAR 2010-11                  FISCAL YEAR 2011-12


1. PERSONNEL SERVICES
                                                                       % FTE (RHSD
                                                                                       FULL TIME ANNUAL      COSTS PAID BY THIS
                         CLASSIFICATION TITLE                          PROGRAMS
                                                                          ONLY)       SALARIES OR WAGES           GRANT

                                                                                                                           $0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00
   TOTAL SALARIES AND WAGES                                                                                                $0.00
  FRINGE BENEFITS (NOT TO EXCEED 32% OF TOTAL SALARIES AND WAGES)                           0.00%
TOTAL PERSONNEL COST (ITEM 1)                                                                                             $0.00

2. OPERATING EXPENSES (e.g. travel, per diem, office supplies, rent)




TOTAL OPERATING EXPENSES (ITEM 2)                                                                                         $0.00


3. OTHER COSTS (e.g. subcontracts, educational materials)




TOTAL OTHER COSTS (ITEM 3)                                                                                                $0.00

4. INDIRECT COST (Not to exceed 10% of Total Salaries and Wages, Excluding Fringe Benefits)
TOTAL INDIRECT COST (ITEM 4)                                                               0.00%


TOTAL BUDGET (SUM OF LINE ITEMS 1 THRU 4)                                                                                 $0.00
                                                                                                           Attachment 8
                                          BUDGET DETAIL WORKSHEET


                      RURAL HEALTH SERVICES DEVELOPMENT (RHSD) PROGRAM
                                       COMPLETE ONLY THE AREAS HIGHLIGHTED IN YELLOW
CORPORATION NAME:                               CLINIC NAME:                         GRANT NUMBER:
                                                                                         09-XXXXX

   X     FISCAL YEAR 2009-10                    FISCAL YEAR 2010-11                  FISCAL YEAR 2011-12


1. PERSONNEL SERVICES
                                                                       % FTE (RHSD
                                                                                       FULL TIME ANNUAL      COSTS PAID BY THIS
                         CLASSIFICATION TITLE                          PROGRAMS
                                                                          ONLY)       SALARIES OR WAGES           GRANT

                                                                                                                           $0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00
   TOTAL SALARIES AND WAGES                                                                                                $0.00
  FRINGE BENEFITS (NOT TO EXCEED 32% OF TOTAL SALARIES AND WAGES)                           0.00%
TOTAL PERSONNEL COST (ITEM 1)                                                                                             $0.00

2. OPERATING EXPENSES (e.g. travel, per diem, office supplies, rent)




TOTAL OPERATING EXPENSES (ITEM 2)                                                                                         $0.00


3. OTHER COSTS (e.g. subcontracts, educational materials)




TOTAL OTHER COSTS (ITEM 3)                                                                                                $0.00

4. INDIRECT COST (Not to exceed 10% of Total Salaries and Wages, Excluding Fringe Benefits)
TOTAL INDIRECT COST (ITEM 4)                                                               0.00%


TOTAL BUDGET (SUM OF LINE ITEMS 1 THRU 4)                                                                                 $0.00
                                                                                                           Attachment 8
                                          BUDGET DETAIL WORKSHEET


                      RURAL HEALTH SERVICES DEVELOPMENT (RHSD) PROGRAM
                                       COMPLETE ONLY THE AREAS HIGHLIGHTED IN YELLOW
CORPORATION NAME:                               CLINIC NAME:                         GRANT NUMBER:
                                                                                         09-XXXXX

   X     FISCAL YEAR 2009-10                    FISCAL YEAR 2010-11                  FISCAL YEAR 2011-12


1. PERSONNEL SERVICES
                                                                       % FTE (RHSD
                                                                                       FULL TIME ANNUAL      COSTS PAID BY THIS
                         CLASSIFICATION TITLE                          PROGRAMS
                                                                          ONLY)       SALARIES OR WAGES           GRANT

                                                                                                                           $0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00
   TOTAL SALARIES AND WAGES                                                                                                $0.00
  FRINGE BENEFITS (NOT TO EXCEED 32% OF TOTAL SALARIES AND WAGES)                           0.00%
TOTAL PERSONNEL COST (ITEM 1)                                                                                             $0.00

2. OPERATING EXPENSES (e.g. travel, per diem, office supplies, rent)




TOTAL OPERATING EXPENSES (ITEM 2)                                                                                         $0.00


3. OTHER COSTS (e.g. subcontracts, educational materials)




TOTAL OTHER COSTS (ITEM 3)                                                                                                $0.00

4. INDIRECT COST (Not to exceed 10% of Total Salaries and Wages, Excluding Fringe Benefits)
TOTAL INDIRECT COST (ITEM 4)                                                               0.00%


TOTAL BUDGET (SUM OF LINE ITEMS 1 THRU 4)                                                                                 $0.00
                                                                                                           Attachment 8
                                          BUDGET DETAIL WORKSHEET


                      RURAL HEALTH SERVICES DEVELOPMENT (RHSD) PROGRAM
                                       COMPLETE ONLY THE AREAS HIGHLIGHTED IN YELLOW
CORPORATION NAME:                               CLINIC NAME:                         GRANT NUMBER:
                                                                                         09-XXXXX

   X     FISCAL YEAR 2009-10                    FISCAL YEAR 2010-11                  FISCAL YEAR 2011-12


1. PERSONNEL SERVICES
                                                                       % FTE (RHSD
                                                                                       FULL TIME ANNUAL      COSTS PAID BY THIS
                         CLASSIFICATION TITLE                          PROGRAMS
                                                                          ONLY)       SALARIES OR WAGES           GRANT

                                                                                                                           $0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00
   TOTAL SALARIES AND WAGES                                                                                                $0.00
  FRINGE BENEFITS (NOT TO EXCEED 32% OF TOTAL SALARIES AND WAGES)                           0.00%
TOTAL PERSONNEL COST (ITEM 1)                                                                                             $0.00

2. OPERATING EXPENSES (e.g. travel, per diem, office supplies, rent)




TOTAL OPERATING EXPENSES (ITEM 2)                                                                                         $0.00


3. OTHER COSTS (e.g. subcontracts, educational materials)




TOTAL OTHER COSTS (ITEM 3)                                                                                                $0.00

4. INDIRECT COST (Not to exceed 10% of Total Salaries and Wages, Excluding Fringe Benefits)
TOTAL INDIRECT COST (ITEM 4)                                                               0.00%


TOTAL BUDGET (SUM OF LINE ITEMS 1 THRU 4)                                                                                 $0.00
                                                                                                           Attachment 8
                                          BUDGET DETAIL WORKSHEET


                      RURAL HEALTH SERVICES DEVELOPMENT (RHSD) PROGRAM
                                       COMPLETE ONLY THE AREAS HIGHLIGHTED IN YELLOW
CORPORATION NAME:                               CLINIC NAME:                         GRANT NUMBER:
                                                                                         09-XXXXX

   X     FISCAL YEAR 2009-10                    FISCAL YEAR 2010-11                  FISCAL YEAR 2011-12


1. PERSONNEL SERVICES
                                                                       % FTE (RHSD
                                                                                       FULL TIME ANNUAL      COSTS PAID BY THIS
                         CLASSIFICATION TITLE                          PROGRAMS
                                                                          ONLY)       SALARIES OR WAGES           GRANT

                                                                                                                           $0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00
   TOTAL SALARIES AND WAGES                                                                                                $0.00
  FRINGE BENEFITS (NOT TO EXCEED 32% OF TOTAL SALARIES AND WAGES)                           0.00%
TOTAL PERSONNEL COST (ITEM 1)                                                                                             $0.00

2. OPERATING EXPENSES (e.g. travel, per diem, office supplies, rent)




TOTAL OPERATING EXPENSES (ITEM 2)                                                                                         $0.00


3. OTHER COSTS (e.g. subcontracts, educational materials)




TOTAL OTHER COSTS (ITEM 3)                                                                                                $0.00

4. INDIRECT COST (Not to exceed 10% of Total Salaries and Wages, Excluding Fringe Benefits)
TOTAL INDIRECT COST (ITEM 4)                                                               0.00%


TOTAL BUDGET (SUM OF LINE ITEMS 1 THRU 4)                                                                                 $0.00
                                                                                                           Attachment 8
                                          BUDGET DETAIL WORKSHEET


                      RURAL HEALTH SERVICES DEVELOPMENT (RHSD) PROGRAM
                                       COMPLETE ONLY THE AREAS HIGHLIGHTED IN YELLOW
CORPORATION NAME:                               CLINIC NAME:                         GRANT NUMBER:
                                                                                         09-XXXXX

   X     FISCAL YEAR 2009-10                    FISCAL YEAR 2010-11                  FISCAL YEAR 2011-12


1. PERSONNEL SERVICES
                                                                       % FTE (RHSD
                                                                                       FULL TIME ANNUAL      COSTS PAID BY THIS
                         CLASSIFICATION TITLE                          PROGRAMS
                                                                          ONLY)       SALARIES OR WAGES           GRANT

                                                                                                                           $0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00
   TOTAL SALARIES AND WAGES                                                                                                $0.00
  FRINGE BENEFITS (NOT TO EXCEED 32% OF TOTAL SALARIES AND WAGES)                           0.00%
TOTAL PERSONNEL COST (ITEM 1)                                                                                             $0.00

2. OPERATING EXPENSES (e.g. travel, per diem, office supplies, rent)




TOTAL OPERATING EXPENSES (ITEM 2)                                                                                         $0.00


3. OTHER COSTS (e.g. subcontracts, educational materials)




TOTAL OTHER COSTS (ITEM 3)                                                                                                $0.00

4. INDIRECT COST (Not to exceed 10% of Total Salaries and Wages, Excluding Fringe Benefits)
TOTAL INDIRECT COST (ITEM 4)                                                               0.00%


TOTAL BUDGET (SUM OF LINE ITEMS 1 THRU 4)                                                                                 $0.00
                                                                                                           Attachment 8
                                          BUDGET DETAIL WORKSHEET


                      RURAL HEALTH SERVICES DEVELOPMENT (RHSD) PROGRAM
                                       COMPLETE ONLY THE AREAS HIGHLIGHTED IN YELLOW
CORPORATION NAME:                               CLINIC NAME:                         GRANT NUMBER:
                                                                                         09-XXXXX

   X     FISCAL YEAR 2009-10                    FISCAL YEAR 2010-11                  FISCAL YEAR 2011-12


1. PERSONNEL SERVICES
                                                                       % FTE (RHSD
                                                                                       FULL TIME ANNUAL      COSTS PAID BY THIS
                         CLASSIFICATION TITLE                          PROGRAMS
                                                                          ONLY)       SALARIES OR WAGES           GRANT

                                                                                                                           $0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00

                                                                                                                            0.00
   TOTAL SALARIES AND WAGES                                                                                                $0.00
  FRINGE BENEFITS (NOT TO EXCEED 32% OF TOTAL SALARIES AND WAGES)                           0.00%
TOTAL PERSONNEL COST (ITEM 1)                                                                                             $0.00

2. OPERATING EXPENSES (e.g. travel, per diem, office supplies, rent)




TOTAL OPERATING EXPENSES (ITEM 2)                                                                                         $0.00


3. OTHER COSTS (e.g. subcontracts, educational materials)




TOTAL OTHER COSTS (ITEM 3)                                                                                                $0.00

4. INDIRECT COST (Not to exceed 10% of Total Salaries and Wages, Excluding Fringe Benefits)
TOTAL INDIRECT COST (ITEM 4)                                                               0.00%


TOTAL BUDGET (SUM OF LINE ITEMS 1 THRU 4)                                                                                 $0.00

				
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