| A | B | C | D | E | |
|---|---|---|---|---|---|
1 | DENTAL FACILITY EXPANSION GRANT | ||||
2 | Overall Grant Budget Form | ||||
3 | FY 2023-2024 | ||||
4 | Name of Clinic or Network: | ||||
5 | |||||
6 | LINE ITEM EXPENSES | Funds Requested from FAFCC | Source of How the Amount of Funding was Determined | Other Funding Sources | Total Project Expenses |
7 | | ||||
8 | | ||||
9 | | ||||
10 | | ||||
11 | | ||||
12 | | ||||
13 | | ||||
14 | | ||||
15 | | ||||
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18 | | ||||
19 | | ||||
20 | | ||||
21 | | ||||
22 | | ||||
23 | | ||||
24 | | ||||
25 | | ||||
26 | | ||||
27 | | ||||
28 | BUDGET TOTAL | $0.00 | $0.00 | $0.00 | |