**Appendix C**

**Page 1 of 7**

**BUDGET FORMS AND INSTRUCTIONS**

**A. Budget Summary For Non-Unit Request (Form 1):**

> [Must be completed by all offerors]{.underline} to summarize the
> request for BHSD funds (Part I) by program category. Specify program
> category requested at the top of Form 1, Appendix C. Use as many pages
> as necessary to display your agency\'s request.
>
> Estimate other funding sources by category in Part II. These other
> funds may be further explained in an attached narrative. Along the
> bottom of the form, total all BHSD and Other Funds by category.
>
> **NOTE**: Offerors must complete a Budget Summary Request for each
> county in which services are proposed.

**B. Non-Unit Item Budget Justification (Form 2)**

> This form is provided for additional budget justification by category.
> New offerors and current contractors must provide a budget narrative.
> Budgeted Expenditure Descriptions are included as part of Appendix C.

**BUDGET SUMMARY Appendix C**

**Page 2 of 7**

**Form 1**

Offeror:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\*County:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Category:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

  -------------------------------------------------- --------------------
  **Part I -- BHSD BUDGET REQUEST**                  **AMOUNT**

  Personnel Services                                 

  Employee Benefits                                  

  In-State Travel                                    

  Maintenance and Repairs                            

  Supplies                                           

  Contractual Services                               

  Operating Costs                                    

  Other Operating Costs                              

  Capital Outlay                                     

  Out-of-State Travel                                

  **TOTAL BHSD BUDGET REQUEST**                      
  -------------------------------------------------- --------------------

  -------------------------------------------------- --------------------
  **Part II - EST. OTHER FUNDING SOURCES**           **AMOUNT**

  Medicaid                                           

  Medicare                                           

  Indian Health Services                             

  Other Federal Funds                                

  Non-Federal Government Funds                       

  United Way                                         

  Private Donations                                  

  Client Fees                                        

  CSAP                                               

  CSAT                                               

  DWI                                                

  Dept. of Ed. Safe and Drug Free Schools &          
  Communities Act                                    

  Other State Funds                                  

  Other                                              

  **TOTAL OTHER FUNDS**                              
  -------------------------------------------------- --------------------

  -------------------------------------------------- --------------------
  **GRAND TOTAL BHSD & OTHER FUNDS**                 

  -------------------------------------------------- --------------------

\* Complete a separate form for each county.

**Appendix C**

#  Page 3 of 7

**Form 2**

**NON-UNIT BUDGET JUSTIFICATION**

Offeror Program Category County \*

**\* Complete a separate form for each county.**

**Appendix C**

**Page [4]{.underline} of [7]{.underline}**

**BUDGETED EXPENDITURE DESCRIPTIONS**

**[PERSONAL SERVICES]{.underline}**

003.0 [Full Time Positions]{.underline}: All full-time, 40-hour
employees.

004.0 [Part Time Positions]{.underline}: All employees hired to work
less than the standard working day or working week.

**[EMPLOYEE BENEFITS]{.underline}**

011.0 [Group Insurance]{.underline}: Group health and accident premiums.

012.0 [Retirement]{.underline}: Retirement contributions.

013.0 [FICA]{.underline}: Social security contributions.

014.0 [Workmen\'s Compensation Premiums]{.underline}

015.0 [Unemployment Compensation]{.underline}

016.0 [Employee Liability Insurance]{.underline}

019.0 [Other Employee Benefits]{.underline}: Specify

**[TRAVEL]{.underline}**

021.0 [In-State Mileage and Fares]{.underline}: Include private car
reimbursement, public transportation fares and parking fees for employee
charges only.

022.0 [In-State Meals and Lodging]{.underline}: Use for employee charges
only. Board and commission expense.

023.0 [Board and Commission Members-In-State Travel]{.underline}:
Include private car reimbursement, car rental, public transportation
fares and parking fees; reimbursement for expenses incurred for
member\'s meals and lodging.

027.0 [Insurance -Transportation]{.underline}: Covers gas and oil for
official vehicles used for travel.

026.0 [Maintenance and Repair - Transportation]{.underline}: Include
replacement parts, commercial repairs, and lube jobs; non-transportation
equipment repair costs should be charged to line item

027.0 [Insurance - Transportation]{.underline}: Include premiums on
travel insurance and coverage on transportation vehicles only; other
equipment insurance premiums are chargeable to line item 034.0,
\"Property Insurance.\"

029.0 [Other Travel]{.underline}: Specify.

**Appendix C**

**Page [5]{.underline} of [7]{.underline}**

**[MAINTENANCE AND REPAIRS]{.underline}**

032.0 [Furniture, Fixtures, and Equipment]{.underline}: Include radio
parts and repairs, maintenance contract for equipment.
[Exclude]{.underline} vehicular repairs chargeable to line item 026.0,
\"Maintenance and Repair Transportation.\"

033.0 [Buildings and Structures]{.underline}: Include interior
decorating and remodeling when such are not capitalized, repairs to or
replacement of boilers, heating systems, and other fixtures permanently
attached to or installed in a building.

034.0 [Property Insurance]{.underline}: Premiums on real and personal
property.

035.0 [Maintenance Supplies]{.underline}: Include janitorial,
sanitation, laundry, and sewing supplies.

036.0 [Laundry and Dry Cleaning]{.underline}: Include uniforms, linens,
drapes, and rags.

037.0 [Maintenance Services]{.underline}: Include contracts for pest
control, janitorial and custodial services.

039.0 [Other Maintenance]{.underline}: Specify.

**[SUPPLIES]{.underline}**

041.0 [Office Supplies]{.underline}: Include printing of calling cards,
all printed forms such as license certificates, receipt forms, citation
blanks, and stationery, also charges for money orders and cashier\'s
checks.

042.0 [Medical, Lab, and Personal Supplies]{.underline}: Include
first-aid kits, clinical thermometers, gauze, tape, crutches, catheters,
barber supplies, toothpaste, shoelaces, razor blades, etc., when
furnished to client without charge, test tubes, developing trays and
chemicals, film and photographic paper for use by agency personnel.

043.0 [Drugs]{.underline}: Includes all drugs and medications.

045.0 [Food]{.underline}: Food items purchased for clients.

046.0 [Kitchen Supplies]{.underline}: Include tableware, expense
utensils, and grill bricks.

047.0 [Uniforms and Linens]{.underline}: Include tablecloths, blankets,
and bed linen.

048.0 [Educational and Recreational Supplies]{.underline}: Include
playing cards, games, textbooks and training materials, nonprofit
canteen supplies, athletic supplies, rental and purchase of movies and
training photographs when such constitute a finished product. Posters
and printing material for distribution to the public, such as
newsletters, pamphlets, etc.

**Appendix C**

**Page [6]{.underline} of [7]{.underline}**

49. [Other Supplies]{.underline}: Specify.

**[CONTRACTUAL SERVICES]{.underline}**

051.0 [Medical Services]{.underline}: Include all charges for medical
services and psychological and physical exams. See also Line Item 073.

052.0 [Professional Services Contracts]{.underline}: Services performed
by professional personnel under contract.

053.0 [Other Contractual Services]{.underline}: Specify; include
research and consultant fees when not covered by a specific line item.

**[OPERATING COSTS]{.underline}**

059.0 [Printing and Photographic Services]{.underline}: Include printing
and binding costs that result in a publication such as a project survey
or annual report; do not include routine office or other forms covered
by line item 041.0 \"Office Supplies.\"

061.0 [Postage]{.underline}: Include postage stamps, stamped cards, and
envelopes (whether printed or not), post office box rent, postage meter
rent, and mail delivery charges.

062.0 [Bond Premiums]{.underline}: Includes bonds on employees.

063.0 [Utilities]{.underline}: Include heat, light, power, water, sewage
and garbage removal charges.

064.0 [Rent of Land and Buildings]{.underline}: Include office and
clinic space; and rooms for public meetings.

065.0 [Rent of Equipment]{.underline}: Include all equipment rental not
charged to travel.

066.0 [Telecommunications]{.underline}: All telephone, telegraph, and
teletype installations and service charges.

067.0 [Subscriptions and Dues]{.underline}: Include license and
registration fees, single copies of expense publications when such
acquisitions are not to become part of a permanent reference library.

069.0 [Advertising]{.underline}: Include all advertising or
advertisements.

**Appendix C**

**Page [7]{.underline} of [7]{.underline}**

**[OTHER OPERATING COSTS]{.underline}**

073.0 [Care and Support]{.underline}: Include payments made to
individuals and non-state institutions and commercial vendors on behalf
of welfare cases and institutional patients, inmates and vocational
rehabilitation clients.

076.0 [Board and Commission Expense]{.underline}: Should only include
reimbursement expenses to board and commission members.

079.0 [Miscellaneous Other Expenses]{.underline}: Specify.

**[CAPITAL OUTLAY]{.underline}**

082.0 [Furniture and Fixtures]{.underline}: Include filing cabinets,
desks, chairs, tables, stands, trays, lamps, drapes, venetian blinds,
rugs and carpets (when not wall-to-wall installation), and shelving
(when not permanently attached to the building).

083.0 [Data Processing Furniture, Fixtures, and Equipment]{.underline}:
Include keypunch machines, computers, sorters, wiring panels, and
storage units used strictly for data processing.

084.0 [Equipment and Machinery]{.underline}: Include typewriters, adding
machines, and communications equipment.

087.0 [Library and Museum Acquisitions]{.underline}: Include all books
and publications purchased for permanent reference use.

088.0 [Automotive]{.underline}: Include passenger cars, pickup trucks
and lighter vehicles used primarily for transportation; covers cost of
accessories when purchased with vehicle as factory or dealer
installation.

**[OUT-OF-STATE TRAVEL]{.underline}**

096.0 [Out-of-State Mileage and Fares]{.underline}: Use for employee
charges only.

097.0 [Out-of-State Meals and Lodging]{.underline}: Use of employee
charges only.

098.0 [Board and Commission Members Out-of-State Mileage and
Fares]{.underline}: Include private car reimbursement, car rental,
public transportation fares and parking fees.

099.0 [Board and Commission Members Out-of-State Meals and
Lodging]{.underline}: Include reimbursement for expenses incurred for
members meals and lodging.