EHDI/TPP Community Grants Program
Request for Proposals
Budget Form
** Instructions **
The funding amounts entered in your Budget Form should match the funding amounts included
in your Budget Narrative.
1. Budget Contact Person
Enter the indicated information about the budget contact person.
2. Annual Budget
For each line item, enter the amount of funding you are requesting from our federal TANF
funds. Include only the total amount for each line item; you do not need to include any detail
on the Budget Form. Your budget should cover the term of the grant, which is October 1,
2012 through June 30, 2013.
3. Supplantation Certification
Type an X in the box to indicate your acceptance of the statutory prohibition on the use of
EHDI funds to supplant existing funds.
EHDI/TPP Community Grants Program
Request for Proposals
Budget Form
1. Budget Contact Person
Budget Contact Person’s Name
Title
Phone
E-mail address
2. First-Year Budget (October 1, 2012 – June 30, 2013)
Line Item
Federal TANF
Funds
Salary and Fringe Benefits
Contractual Services
Travel
Supplies and Expenses
Other
Administrative Costs
Total
3. Supplantation Certification
(check)
The applicant certifies that EHDI funds will be used to develop new activities,
expand or modify current activities that work to reduce health disparities, and/or
replace discontinued funds from the state, the federal government, or another third
party previously used to reduce health disparities. The applicant will not
voluntarily opt to use EHDI funds to replace federal, state, local, or tribal funding
it currently uses to reduce health disparities.