HYBRID FEE FOR SERVICE BUDGET FORM (Table I.C.)
You must complete this form if you are submitting a “hybrid” (transaction) fee for service budget
Service Category: Title of Service:
1.
Fee Charged per Service Transaction:
$
2.
Number of Service Transactions to be Provided:
3. 4.
Total Cost of these Services (#1 x #2): Breakdown of Fee per Service Transaction:
$
SUBTOTAL
$ $ $ $ $ $ $ $ $ $
5.
Definition of Service Transaction: 1 unit of service =
6.
Total Amount of Funds to be Invoiced (e.g., dollar amount of assistance vouchers, diagnostic procedures, etc.) Total Budget Request (#3 + #6):
$
7.
$
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