Applicant/Provider:

Enter the Applicant's legal name.

RFP#:

Enter the Request For Proposal (RFP) identifying number of this service activity.

For all columns

(a) thru (d)

Report your total organization-wide budget for this fiscal year by source of funds.  Your organization's budget should reflect the total budget of the "organization" legally named.  Report each source of fund in separate columns, by budget line item.

For the first column on the first page of this form, use the column heading, "Organization Total".

For the remaining columns you may use column headings such as:  Federal, State, Funds Raised, Program Income, etc.  If additional columns are needed, use additional copies of this form.

Columns (b), (c) & (d)

Identify sources of funding in space provided for column titles.

TOTAL (A+B+C+D)

Sum the subtotals for Budget Categories A, B, C and D, for columns (a) through (d).

SOURCE OF FUNDING:

(a)

(b)

(c)

(d)

Identify all sources of funding to be used by your organization.

TOTAL REVENUE

Enter the sum of all revenue sources cited above.

Budget Prepared by:

Type or print the name of the person who prepared the budget request and their telephone number.  If there are any questions or comments, this person will be contacted for further information and clarification.

Provide signature of Applicant's authorized representative, and date of approval.