The HealthPath Foundation of Ohio

Oral Health Capacity Building

Technical Assistance Project

Budget Request Form

Organization: __

Project Title: Budget Year:

Revenues

/ ProjectRevenues
HealthPath Foundation of Ohio Request (oneyear) / NA
Income Generated from Services / NA
Other Grants & Funding / NA
In-kind / NA
Other (specify in line item narrative) / NA
Total Revenue : / NA
Expenses: / Project Expenses / Amount Requested from HealthPath
Salaries
Fringe benefits and payroll taxes
Consultants
Travel
Conferences, Training & Meetings
Equipment
Supplies
Printing and copying
Postage
Rent and utilities (include telephone & fax) *
Other (specify in line item narrative)
Total Expenses/Total HealthPath Request (6 mos.)

*only reasonable and related overhead costs will be covered by any HealthPath Foundation grant. The Foundation does not pay any flat-rate indirect cost or overhead allowances.

Budget Request Form Instructions

The Budget Request Form is used to help us understand the total project budget and the specific use of funds from The HealthPath Foundation of Ohio (Foundation). Please provide a separate line item narrative to explain the costs included in each entry.

  • The first column asks for the projected budget of the proposed project. Show the total revenue expected for the time period covered, including the grant that you are requesting from the Foundation. The amount you enter here should be for 6 months of funding. Be sure to include any in-kind contributions from the lead agency or collaborating partners. Show total expenses for the proposed project. The total for Project Revenues should equal total Project Expenses.
  • The second column shows the line item expense budget that the applicant would like the Foundation to fund.
  • Line Item Definitions:

Revenues

HealthPath Foundation Grant Request: Enter the amount requested for 6 months of funding.

Income Generated from Services: Include any revenues you expect to generate as a result of your project, including payments through Medicaid, insurance or sliding fees.

Other Grants & Funding: List other sources of funding (foundation, corporate, government, or individual grants/contributions) for this project, if applicable.

In-Kind: List all non-cash contributions to the project, including donated equipment, supplies, facility costs, or time from existing staff assigned to this project.

Other: Include any other sources of revenue for your project.

Expenses

Salaries: Include all staff salaries allocated to the project. Identify position, salary and percentage of time devoted to the project. Indicate whether positions are new or existing.

Fringe benefits and payroll taxes: Include benefits and taxes allocable to the salaries listed above. Identify percentage used to calculate fringe benefits.

Consultants: Include all fees, honoraria and expenses for consulting and professional services of individuals or organizations that are not paid staff of the organization. Describe the type of consulting and professional services you anticipate purchasing. If possible, estimate the cost for each scope of service separately. In line item narrative, identify the consultants you intend to hire and their qualifications, if possible.

Travel: Include all expenses related to local travel and mileage reimbursement.

Conferences, Training & Meetings: Include facility, registration fees and meal expenses.

Equipment: Identify each specific item and estimated cost.

Supplies: Include all office supplies, subscriptions, books, and other materials.

Printing & Copying: Include expenses for all producing all printed materials. Identify any publications and the number of copies planned.

Postage: Include all postage and delivery expenses.

Rent & Utilities: If applicable, include charges for office space and indicate percent of total being charged to the project. Utility charges should include phone, fax and internet.