Key TOTAL $10,896

Item(s) Rate Cost

General office supplies $50/mo. x 12 mo. $600
Postage $37/mo. x 8 mo. $296
Laptop Computer $900 $900
Printer $300 $300
Projector $900 $900
Copies 8000 copies x .10/copy $800
TOTAL $3,796

JUSTIFICATION: Describe the need and include an adequate justification of how

eachcost was estimated.

(1) Office supplies, copies and postage are needed for general operation of the
project.

(2) The laptop computer is needed for both project work and presentations.

(3) The projector is needed for presentations and outreach workshops.

All costs were based on retail values at the time the application was written.

NON-FEDERAL MATCH

Item(s) Rate Cost

General office supplies $50/mo. x 12 mo. $600
Bookcase $75 $75
Digital camera $300 $300
Fax machine $150 $150
Computer $500 $500
Postage $37/mo. x 4 mo $148
TOTAL $1,773

JUSTIFICATION: Describe need and include explanation of how costs were

estimated.

(1) The local television station is donating the bookcase, camera, fax machine, and
computer (items such as these can only be claimed as match once during the grant
cycle and used for the project). The “applying agency” is donating the additional costs
for office supplies and postage.

1
FEDERAL REQUEST (enter in Section B column 1, line 6e of form SF424A)$3,796

NON-FEDERAL MATCH(enter in Section B column 2, line 6e of form SF424A)$1,773

F. Contract:A contractual arrangement to carry out a portion of the programmatic effort

or for the acquisition of routine goods or services under the grant. Such arrangements
may be in the form of consortium agreements or contracts. A consultant is an individual
retained to provide professional advice or services for a fee. The applicant/grantee
must establish written procurement policies and procedures that are consistently
applied. All procurement transactions shall be conducted in a manner to provide to the
maximum extent practical, open and free competition.

COSTS FOR CONTRACTS MUST BE BROKEN DOWN IN DETAIL AND NARRATIVE

JUSTIFICATION. IF APPLICABLE, NUMBERS OF CLIENTS SHOULD BE
INCLUDED IN THE COSTS.

FEDERAL REQUEST

Name Service Rate Other Cost

(1) State
Department of $250/individual x
Training 5 days $750
Human 3 staff
Services

(2) Treatment $27/client per

1040 Clients $28,080
Services year

*Travel at 3,124
@ .50 per mile
= $1,562
*Training course
$175
*Supplies @
1FTE @ $27,000
(3) Jane Doe Treatment $47.54 x 12
+ Fringe Benefits
(Case Client months or $570 $46,167
of $6,750 =
Manager) Services *Telephone @
$33,750
$60 x 12
months = $720
*Indirect costs =
$9,390
(negotiated with
contractor)

2
Name Service Rate Other Cost
$40 per hour x
(4) Jane Doe Evaluator 12 month period $9,000
225 hours

Annual salary of
(5) To Be Marketing
$30,000 x 10% $3,000
Announced Coordinator
level of effort
TOTAL $86,997

JUSTIFICATION:Explain the need for each contractual agreement and how they
relate to the overall project.

(1) Certified trainers are necessary to carry out the purpose of the statewide
consumer Network by providing recovery and wellness training, preparing
consumer leaders statewide, and educating the public on mental health recovery.

(2) Treatment services for clients to be served based on organizational history of

expenses.

(3) Case manager is vital to client services related to the program and outcomes.

(4) Evaluator is provided by an experienced individual (Ph.D. level) with expertise in

substance abuse, research and evaluation and is knowledgeable about the target
population and will report GPRA data.

(5) Marketing Coordinator will develop a plan to include public education and
outreach efforts to engage clients of the community about grantee activities,
provision of presentations at public meetings and community events to
stakeholders, community civic organizations, churches, agencies, family groups
and schools.

* Represents separate/distinct requested funds by cost category

NON-FEDERAL MATCH(Consultant)

Name Service Rate Other Cost

Outreach $43.00/hr. x 20
Jane Doe meeting hrs./month x 12 $10,320
facilitation months
148
Travel miles/month@ .
$675
Expenses 38/mile x 12
months

3
Name Service Rate Other Cost
TOTAL $11,051

JUSTIFICATION:Explain the need for each agreement and how they relate to the
overall project.

(1) Facilitator volunteering his/her time to facilitate the youth prevention and
outreach sessions outlined in the strategic plan. Hourly rate is based on an
average salary of an outreach facilitator in the geographic area.

(2) Travel is based on average distance between facilitator’s location and the
meeting site. Mileage rate is based on POV reimbursement rate.

NON-FEDERAL MATCH (Contract)

Entity Product/Service Cost

Student Assistance
(1) West BankSchool
Program for 50 students $15,000
District
@ $300 per year
TOTAL $15,000

JUSTIFICATION:Explain the need for each agreement and how they relate to the
overall project.

(1) West BankSchool District is donating their contracted services to provide drug
testing, referral and case management for 50 non-school attending youth.
Average cost is $300/person.

FEDERAL REQUEST (enter in Section B column 1, line 6f of form SF424A)$86,997

NON-FEDERAL MATCH(enter in Section B column 2, line 6f of form SF424A)$26,051

G. Construction:NOT ALLOWED – Leave Section B columns 1&2 line 6g on SF424A

blank.

H. Other: expenses not covered in any of the previous budget categories

FEDERAL REQUEST

Item Rate Cost

(1) Rent* $15/sq.ft x 700 sq. feet $10,500
(2) Telephone $100/mo. x 12 mo. $1,200
$10/client follow up x 278
(3) Client Incentives $2,780
clients

4
 Item Rate Cost
.89/brochure X 1500
(4) Brochures $1,335
brochures
TOTAL $15,815

JUSTIFICATION: Break down costs into cost/unit (e.g. cost/square foot, etc.).
Explain the use of each item requested.

(1) Office space is included in the indirect cost rate agreement; however, if other rental
costs for service site(s) are necessary for the project, it may be requested as a direct
charge. The rent is calculated by square footage or FTE and reflects SAMHSA’s fair
share of the space.

*If rent is requested (direct or indirect), provide the name of the owner(s) of the
space/facility. If anyone related to the project owns the building which is less
than an arms-length arrangement, provide cost of ownership/use allowance
calculations. Additionally, the lease and floor plan (including common areas) is
required for all projects allocating rent costs.

(2) The monthly telephone costs reflect the % of effort for the personnel listed in this
application for the SAMHSA project only.

(3) The $10 incentive is provided to encourage attendance to meet program goalsfor
278 client follow-ups.

(4) Brochures will be used at various community functions (health fairs and exhibits).

NON-FEDERAL MATCH

Item Rate Cost

(1) Space rental $75/event x 12 events/year $900
(2) Internet services $26/mo. x 12 mo. $312
(3) Student surveys $1/survey x 1583 surveys $1,583
.97/brochure x 1500
(4) Brochures $1,455
brochures
TOTAL $4,250

JUSTIFICATION:Breakdown costs into cost/unit: i.e. cost/square foot. Explain

the use of each item requested.

(1) Donated space for the various activities outlined in the scope of work, such as
teen night out, after-school programs, and parent education classes.

(2) The applying agency is donating the internet services for the full-time
coordinator.

5
 (3) The ABC Company is donating the cost of 1,583 for student surveys.

(4) The ABC Company is donating the printing costs for the bi-monthly brochures.

All costs are the value placed on the service at the time of this grant application.

FEDERAL REQUEST (enter in Section B column 1, line 6h of form SF424A) $15,815

NON-FEDERAL MATCH-(enter in Section B column 2, line 6h of form SF424A) $4,250

J. Indirect Charges:indirect costs to be charged to the grant

Indirect cost rate: Indirect costs can only be claimed if your organization has a
negotiatedindirect cost rate agreement or cost allocation plan. It is applied only to direct
costs to the agency as allowed in the agreement or cost allocation plan. For information
on applying for an indirect cost rate agreement go to: http://www.samhsa.gov then click
on grants – Grants Management – Contact Information – Important Offices at SAMHSA
and DHHS - HHS Division of Cost Allocation – Regional Offices.

Attach a copy of the current fully executed, negotiated agreement indirect cost
rate agreement or cost allocation plan. The applicable indirect cost rate(s)
negotiated by the organization with the cognizant negotiating agency must be
used in computing indirect costs (F&A) for a proposal (2 CFR §200.414). The
amount for indirect costs should be calculated by applying the current negotiated
indirect cost rate(s) to the approved base(s).

FEDERAL REQUEST (enter in Section B column 1, line 6j of form SF424A)

8% of personnel and fringe (.08 x $63,661) $5,093

NON-FEDERAL MATCH (enter in Section B column 2, line 6j of form SF424A)

8% of personnel and fringe(.08 x $26,037) $2,083

==================================================================

TOTAL DIRECT CHARGES:

FEDERAL REQUEST– (enter in Section B column 1 line 6i of form SF424A)$172,713

NON-FEDERAL MATCH -(enter in Section B column 2 line 6i of form SF424A) $59,348

INDIRECT CHARGES:

6
FEDERAL REQUEST –(enter in Section B column 1 line 6j of form SF424A)$5,093

NON-FEDERAL MATCH–(enter in Section B column 2 line 6j* of form SF424A)$2,083

TOTALS: (sum of 6i and 6j)

FEDERAL REQUEST – (enter in Section B column 1 line 6k of form SF424A)$177,806

NON-FEDERAL MATCH-(enter in Section B column 2 line 6k of form SF424A)$61,431

==================================================================

UNDER THIS SECTION REFLECT OTHER NON-FEDERAL SOURCES OF FUNDING

BY DOLLAR AMOUNT AND NAME OF FUNDER e.g., Applicant, State, Local,
Other, Program Income, etc.Other support is defined as all funds or resources,
whether Federal, Non-federal or institutional, in direct support of activities
through fellowships, gifts, prizes, In-kind contributions or other Non-federal
means.

Provide the total proposed Project Period Federal & Non-Federal funding as
follows:

Proposed Project Period

a. Start Date: 09/30/2011 b. End Date: 09/29/2016

BUDGET SUMMARY (should include future years and projected total)

Category Federal Non-Federal Year 2 Year 2 Non- Year 3 Year 3 Non- Year 4 Year 4 Year 5 Year 5
Request Match for Federal Federal Federal Federal Federal Non- Federal Non-
For Year 1 Request* Match * Request* Match* Request* Federal Request* Federal
Year 1 Match* Match*
Personnel $52,765 $21,580 $54,348 $1,338 $55,978 $40,000 $57,658 $35,000 $59,387 $43,000
Fringe $10,896 $4,457 $11,223 $275 $11,558 $8,260 $11,906 $7,228 $12,263 $8,880
Travel $2,444 $1,237 $2,444 $2,000 $2,444 $1,500 $2,444 $1,200 $2,444 $2,600
Equipment 0 0 0 0 0 0 0 0 0 0
Supplies $3,796 $1,773 $3,796 $2,000 $3,796 $2,000 $3,796 $2,500 $3,796 $4,500
Contractual $86,997 $26,051 $86,997 $67,000 $86,997 $15,000 $86,997 $10,000 $86,997 $14,500
Other $15,815 $4,250 $13,752 $52,387 $11,629 $5,786 $9,440 $8,976 $7,187 $4,000
Total Direct
$172,713 $59,348 $172,560 $125,000 $172,403 $72,546 $172,241 $64,904 $172,074 $77,480
Charges

Indirect
$5,093 $2,083 $5,246 $129 $5,403 $3,861 $5,565 $3,378 $5,732 $4,150
Charges

Total Project
$177,806 $61,431 $177,806 $125,129 $177,806 $76,407 $177,806 $68,282 $177,806 $81,630
Costs

7
 Category Federal Non-Federal Year 2 Year 2 Non- Year 3 Year 3 Non- Year 4 Year 4 Year 5 Year 5
Request Match for Federal Federal Federal Federal Federal Non- Federal Non-
For Year 1 Request* Match * Request* Match* Request* Federal Request* Federal
Year 1 Match* Match*

TOTAL PROJECT COSTS: Sum of Total Direct Costs and Indirect Costs

FEDERAL REQUEST (enter in Section B column 1 line 6k of form SF424A)$889,030

NON-FEDERAL MATCH(enter in Section B column 2 line 6k of form SF424A)$412,879

* FOR REQUESTED FUTURE YEARS:

1. Please justify and explain any changes to the budget that differs from the
reflected amounts reported in the 01 Year Budget Summary.

2. If a cost of living adjustment (COLA) is included in future years, provide your

organization’s personnel policies and procedures that state all employees within
the organization will receive a COLA.