Attachment E: HCV Project Budget Template.xlsx

	B	C	D	E	F	G	H	I
1
2	Colorado Department of Public Health and Environment BUDGET JUSTIFICATION FORM
3		Contract Routing #
4
5
6
7	Contractor Name			Program Contact Name, Title, Phone and Email
8	Budget Period	8/1/2022-6/30/2023		Fiscal Contact Name, Title, Phone and Email
9	Project Name	HCV
10
11
12
13	Expenditure Categories
14	Personal Services		Gross or Annual Salary	Fringe	Percent of Actual Time (FTE) on Contract/ Purchase Order	Service Category	Match or In-Kind (If Applicable)	Total Amount Requested from CDPHE
15	Position Title/Employee Name	Description of Work (for hourly employees, please include the hourly rate and number of hours in your description)
16						Leave Blank		$0.00
17						Leave Blank		$0.00
18						Leave Blank		$0.00
19						Leave Blank		$0.00
20						Leave Blank		$0.00
21						Leave Blank		$0.00
22						Leave Blank		$0.00
23						Leave Blank		$0.00
24	Total Personal Services by Employee (including fringe benefits)						$0.00	$0.00
25	Personal Services Service Category Splits						Percent of Entire Team's Actual Time (FTE) on Contract/ Purchase Order	Total Amount Per Service Category
26								$0.00
27								$0.00
28								$0.00
29								$0.00
30	Total Personal Services by Service Category (Must Match Total Personal Services by Employee)						0%	$0.00
31	Supplies & Operating Expenses
32	Item	Description of Item		Rate	Quantity	Service Category	Match or In kind (if applicable)	Total Amount Requested from CDPHE
33
34
35
36
37
38
39
40
41
42
43
44
45	Total Supplies & Operating Expenses						$0.00	$0.00
46	Travel
47	Item	Description of Item		Rate	Quantity	Service Category	Match or In kind (if applicable)	Total Amount Requested from CDPHE
48	Mileage
49
50
51
52
53
54	Total Travel						$0.00	$0.00
55	Other Costs
56	Item	Description of Item		Rate	Quantity	Service Category	Match or In kind (if applicable)	Total Amount Requested from CDPHE
57
58
59
60
61
62
63	Total Other Costs						$0.00	$0.00
64	Contractual (payments to third parties or entities)
65	Item	Subcontractor Entity Name and/or Description of Item		Rate	Quantity	Service Category	Match or In kind (if applicable)	Total Amount Requested from CDPHE
66
67
68
69
70
71
72	Total Contractual						$0.00	$0.00
73	SUB-TOTAL BEFORE INDIRECT							$0.00
74	Indirect
75	Item	Description of Item				Service Category
76	Indirect cost rate by reporting category
77
78
79
80
81
82
83	Total Indirect						$0.00	$0.00
84	TOTAL MATCH OR IN KIND						$0.00
85	TOTAL							$0.00
86
87	Reporting Categories	Category of Service		Direct Costs	Indirect Costs		Total Costs
88	STATE 23	HCV Testing		$0.00	$0.00		$0.00
89	STATE 37	HCV Education		$0.00	$0.00		$0.00
90	STATE 73	HCV Linkage to Care		$0.00	$0.00		$0.00
91	STATE 83	HCV Linkage to Care Coordination		$0.00	$0.00		$0.00
92				$0.00	$0.00		$0.00
93				$ -	$0.00		$0.00
94
95
96
97
98
99
100