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1
2
3
PREVENTION SERVICES DIVISION- ADVANCE PAYMENT 12 MONTH BUDGET WITH JUSTIFICATION FORM
4
Original Contract Routing #
5
6
Contractor NameProgram Contact Name, Title, Phone and Email
7
Budget PeriodFiscal Contact Name, Title, Phone and Email
8
Project Name
9
10
11
Expenditure Categories
12
Personal Services
Salaried Employees
13
Position TitleDescription of Work Gross or Annual SalaryFringePercent of Time on ProjectTotal Amount Requested from CDPHE
14
-
15
-
16
-
17
-
18
-
19
-
20
-
21
-
22
-
23
-
24
-
25
-
26
-
27
-
28
-
29
Personal Services
Hourly Employees
30
Position TitleDescription of Work Hourly WageHourly FringeTotal # of Hours on ProjectTotal Amount Requested from CDPHE
31
-
32
-
33
-
34
-
35
-
36
-
37
-
38
-
39
-
40
-
41
-
42
-
43
-
44
Total Personal Services (including fringe benefits)-
45
Supplies & Operating Expenses
46
ItemDescription of ItemRateQuantityTotal Amount Requested from CDPHE
47
-
48
-
49
-
50
-
51
-
52
-
53
-
54
-
55
-
56
-
57
-
58
-
59
-
60
-
61
-
62
-
63
Total Supplies & Operating-
64
Travel
65
ItemDescription of ItemRateQuantityTotal Amount Requested from CDPHE
66
-
67
-
68
-
69
-
70
-
71
-
72
-
73
-
74
-
75
-
76
-
77
-
78
-
79
Total Travel-
80
Contractual
81
Subcontractor NameDescription of ItemRateQuantityTotal Amount Requested from CDPHE
82
-
83
-
84
-
85
-
86
-
87
-
88
-
89
-
90
-
91
-
92
-
93
Total Contractual-
94
SUB-TOTAL OF DIRECT COSTS-
95
Indirect
96
ItemDescription of ItemPercentageTotal Amount Requested from CDPHE
97
Federally-Negotiated Indirect Cost Rate-
98
CDPHE-Negotiated Indirect Cost Rate20%- add or subtract cents to this row's calculation to ensure total amount is a round dollar amount
99
Total Indirect-
100
TOTAL-