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(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, they 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) Teleconference costs for SS/HS program grantees. (4) Teleconference costs for Project LAUNCH grantees (5) Printing costs for SS/HS information pamphlets (6) Printing costs for Project LAUNCH information pamphlets. FEDERAL REQUEST – (enter in Section B column 1 line 6h of form SF-424A) $15,815 Indirect Cost Rate: Indirect costs can be claimed if your organization has a negotiated indirect cost rate agreement. It is applied only to direct costs to the agency as allowed in the agreement. For information on applying for the indirect rate 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. FEDERAL REQUEST (enter in Section B column 1 line 6j of form SF-424A) 8% of personnel and fringe (.08 x $742,001) $59,360 ================================================================== TOTAL DIRECT CHARGES: FEDERAL REQUEST – (enter in Section B column 1 line 6i of form SF-424A) $172,713 INDIRECT CHARGES: FEDERAL REQUEST – (enter in Section B column 1 line 6j of form SF-424A) $59,360 TOTALS: (sum of 6i and 6j) 52
FEDERAL REQUEST – (enter in Section B column 1 line 6k of form SF-424A) $1,194,067 ================================================================== UNDER THIS SECTION REFLECT OTHER FEDERAL AND 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 funds or resources, whether federal, non-federal or institutional, in direct support of activities through fellowships, gifts, prizes, inkind contributions or non-federal means. [Note: Please see Appendix F, Funding Restrictions, regarding allowable costs.]Provide the total proposed project period and federal funding as follows: Proposed Project Period a. Start Date: 09/30/2013 b. End Date: 09/29/2017 BUDGET SUMMARY (should include future years and projected total) Category Year 1 Year 2* Year 3* Year 4* Total Project Costs Personnel $615,000 $615,00 $615,000 $615,000 $2,460,000 Fringe $127,001 $127,001 $127,001 $127,001 $508,004 Travel $5,272 $5,272 $5,272 $5,272 $12,220 Equipment 0 0 0 0 0 Supplies $5,320 $5,320 $5,320 $5,320 $21,280 Contractual $217,334 $217,334 $217,334 $217,334 $869,336 Other $164,780 $164,780 $164,780 $164,780 $659,120 Total Direct Charges Indirect Charges $1,134,707 $1,134,707 $1,134,707 $1,134,707 $4,538,828 $59,360 $59,360 $59,360 $59,360 $237,440 53
Page 1 and 2: Department of Health and Human Serv
Page 3 and 4: Appendix B - Guidance for Electroni
Page 5 and 6: Cost Sharing/Match Required: No Len
Page 7 and 8: programming and policies will be ac
Page 9 and 10: • Assist grantees with developing
Page 11 and 12: • Participate in state, regional,
Page 13 and 14: Freedom (OIF), and Operation New Da
Page 15 and 16: and performance assessment, e.g., a
Page 17 and 18: Tribal organization means the recog
Page 19 and 20: (demographics and clinical characte
Page 21 and 22: Your application must be received b
Page 23 and 24: Section B: Proposed Approach (35 po
Page 25 and 26: • Demographics - race, ethnicity,
Page 27 and 28: Note: There should be separate colu
Page 29 and 30: termination of the grant award, or
Page 31 and 32: Appendix A - Checklist for Formatti
Page 33 and 34: Appendix B - Guidance for Electroni
Page 35 and 36: that these issues will be resolved
Page 37 and 38: • Name, telephone number, and e-m
Page 39 and 40: o Documentation of nonprofit status
Page 41 and 42: grant applications submitted by com
Page 43 and 44: prevention provider may also provid
Page 45 and 46: Appendix F - Sample Budget and Just
Page 47 and 48: FEDERAL REQUEST Purpose of Travel L
Page 49 and 50: Item(s) Rate SS/HS Costs Project LA
Page 51: (2) Consultant is needed to provide
Page 55 and 56: Appendix G - Confidentiality and SA
Page 57 and 58: Appendix H- Addressing Behavioral H
Page 59 and 60: You can learn more about the CLAS m
Page 61 and 62: Appendix I - Sample Logic Model A l
Page 63 and 64: Sample Logic Model 63

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