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Rental Agreements Leases

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					                                                KANSAS DEPARTMENT OF HEALTH AND ENVIRONMENT
                                               H1N1 PHASE IV PUBLIC HEALTH EMERGENCY RESPONSE
                                    PHER Phase 4 - LINE ITEM BUDGET & JUSTIFICATIONS
                                 ****************************************************************************************************


AGENCY NAME:                                                                                                     Phone


GRANT PERIOD:                            February 22, 2009 - July 30, 2010                                        Email:



GRANT TITLE:                                                  2009-2010 H1N1 Emergency Response Phase IV



                 EXPENDITURE CLASSIFICATION & JUSTIFICATION                                             Line Item Amounts (Each)            Line Totals
PERSONNEL - Salaries, Wages, Fringes

(Please list each staff member/position, salary, percent FTE, and amount of time to be paid with PHER Phase 4 funds)




                                                                                                           Sub-total Personnel          $                  -
TRAVEL - Mileage, Meals, Lodging, Parking/Toll

(Please list travel, dates of travel, purpose of travel and why it is necessary to fulfill PHER program goals/needs, per diem costs, any hotel, meal, or
other miscellaneous costs associated with travel)




                                                                                                              Sub-total Travel          $                  -
SUPPLIES - Office, Medical, Exercise/Clinic/POD

(Please provide itemized justification of supplies, including unit costs, total amount needed, and why supplies are necessary to fulfill PHER program
goals/needs)




                                                                                                            Sub-total Supplies          $                  -
EQUIPMENT - PPE, Communications, IT, POD

(Please provide detailed description of supplies, including unit costs, total amount needed, and why equipment is necessary to fulfill PHER program
goals/needs)




                                                                                                           Sub-total Equipment          $                  -
CONTRACTUAL - Subcontracts (Personnel), Services (IT Service Agreements, Leases/Rental Agreements)

(Please list each contractor separately, describing the scope of work to be conducted by the contractor,also providing a line item justification
describing the work to be performed in the contract, and explaining why the contract is necessary to fulfill PHER program goals/needs)




                                                                                                           Sub-total Contractual        $                  -
                                             KANSAS DEPARTMENT OF HEALTH AND ENVIRONMENT
                                            H1N1 PHASE IV PUBLIC HEALTH EMERGENCY RESPONSE
                                 PHER Phase 4 - LINE ITEM BUDGET & JUSTIFICATIONS
                              ****************************************************************************************************


AGENCY NAME:                                                                                                  Phone


GRANT PERIOD:                         February 22, 2009 - July 30, 2010                                        Email:



GRANT TITLE:                                               2009-2010 H1N1 Emergency Response Phase IV

OTHER - Subscriptions (Internet, Cellular, Telephone, KIPHS User Fees), Other (Pamphlets/Media, Meeting Expenses, Postage, Administrative
Fees, Training/Education)

(Please list each item separately, describing scope of work and line item justifications when necessary, justifying why these items/services are
necessary to fulfill PHER program goals/needs)




                                                                                                           Sub-total Other                   $         -


                                                                                              TOTAL BUDGETED PHASE 4 COSTS                   $     -



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SIGNATURE                                                                                                                            DATE


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