Annual Budget

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					DEPARTMENT OF HEALTH SERVICES                                                                                           STATE OF WISCONSIN
Division of Long Term Care
F-00052A (11/2009)

                  AGING AND DISABILITY RESOURCE CENTER (ADRC) ANNUAL BUDGET
Completion of this form is voluntary; however, the information requested is required as part of the ADRC application process.
Line Item Budget: Include the following information
                                         ADRC Grant                              Other Funding 1     Other Funding 2
                                          Funding          MA Match Funding      (identify below)    (identify below)        Grand Total

ADRC Program Personnel
Salary                                                                                                                                     0
Fringe                                                                                                                                     0
                          Subtotal                    0                      0                  0                   0                      0
Direct Expenses
Travel                                                                                                                                     0
Training                                                                                                                                   0
Printing                                                                                                                                   0
Postage                                                                                                                                    0
Office Supplies                                                                                                                            0
Telephone                                                                                                                                  0
Computer & related                                                                                                                         0
Rent/Lease                                                                                                                                 0
Equipment                                                                                                                                  0
Equipment Maintenance                                                                                                                      0
Certifications/Professional Dues                                                                                                           0
Translation Services                                                                                                                       0
Outreach/Marketing                                                                                                                         0
                                                                                                                                           0
                                                                                                                                           0
                                                                                                                                           0
                                                                                                                                           0
                                                                                                                                           0
                                                                                                                                           0
                          Subtotal                    0                      0                  0                   0                      0
Indirect Expenses
Administration/AMSO                                                                                                                        0
                                                                                                                                           0
                                                                                                                                           0
                          Subtotal                    0                      0                  0                   0                      0
Subcontracts
                                                                                                                                           0
                                                                                                                                           0
                                                                                                                                           0
                                                                                                                                           0
                          Subtotal                    0                      0                  0                   0                      0

             TOTAL EXPENSES                           0                      0                  0                   0                      0
Other Funding 1:
Other Funding 2:
NOTE: Insert additional lines as needed. Complete and/or add lines in Direct Expenses as appropriate.
DEPARTMENT OF HEALTH SERVICES                                                                                           STATE OF WISCONSIN
Division of Long Term Care                                                                                                           Page 2
F-00052A (11/2009)
                                         ADRC BUDGET: PERSONNEL WORKSHEET
Completion of this form is voluntary; however, the information requested is required as part of the ADRC application process.
                                                                                                                    Percent FTE    Percent FTE
                         Name - Staff (First      All Functions* (ADRC and other)        Total FTE Annual Salary funded by       funded by other
                            name and last      performed by this person (see example      for this     per person    ADRC** (all    source (list
   Position Title               initial)                       below)                     person      (not fringe)      funds)       sources)
Director and Supervisors Section




Other Staff Section




                                                                          TOTALS               0           0.00

* Such as I & A, Disability Benefit Specialist (DBS), outreach, etc. Include non-ADRC activities. One staff member per line.
** Include contract and federal match in the amount--do not need to break out ADRC contract and federal percent.
EXAMPLE:
                                             I&A, options counseling, enrollment
                                            counseling, LTCFS, outreach for                                                   .1 MIPPA, .3
                                            MIPPA grant, APS, other non-ADRC                                                  APS, .1 county
ADRC Specialist        Jane S.              function                                            1     40000.00            50% levy
DEPARTMENT OF HEALTH SERVICES                                                                                     STATE OF WISCONSIN
Division of Long Term Care                                                                                                     Page 3
F-00052A (11/2009)


                                   ADRC BUDGET: SUBCONTRACT WORKSHEET
Completion of this form is voluntary; however, the information requested is required as part of the ADRC application process, when
appropriate.

         Name - Contractor                      Contracted Work                     Name - Staff *            FTE             Cost




                                                                                                     TOTAL                           0
* List if contracted work is performed by an ADRC staff member; one staff member per line.
EXAMPLE
If subcontract is for marketing, you would not fill in staff name; however, if subcontract is for DBS, you would fill in name and