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<br />BUDGET <br />(Period 07/O1/C8 to 06/30/09 ) <br />Applicant/Provider: ~`~i ~h' Office of the pmsewting AttArn23 <br />RFP No.: <br />Contract No. (As Applicable): <br />BUDGET <br />CATEGORIES Total FP <br />Prog Budget <br />(a) Title X <br />Request <br />(b) <br /> <br />(c) , <br /> <br />(d) <br />A. PERSONNEL COST <br />1. Salaries <br />2. a roll axes & ssessments <br />3. nn a ene its <br />TOTAL PERSONNEL COST <br />B. OTHER CURRENT EXPENSES <br />1. Airfare, Inter-Island <br />~ <br />2. are, ut-o -S ate <br />3. Audit Servces 800 <br />4.. ontractua Sernces- mmistraGve 0 <br />5. ontractua Services- u n acts <br />6. nsurance <br />eas enta o w men 0 <br />8. eas Rental 0 0 or a is a 300 <br />9. ease/Ren a o ace 800 <br />0. i ea e <br />14. osta a rei ewe Z00 <br />u ira on & P nbn 4960 <br />13. Re au aintenance 0 <br />14. to ramin 9000 <br />15. u Stan er iem 790 <br />6, u ies <br /> <br /> <br /> <br />2 7?uhl icati <br />TOTAL OTHER CURRENT EXPENSES <br />C. EQUIPMENT PURCHASES <br />D. MOTOR VEHICLE PURCHASES 0 <br />TOTAL BUDGET ,000 <br /> <br />PROGRAM INCOME: Budget Prepared By: <br />~°~ L• ~ (0934-335 <br />a Client Collections/Self Pa Name (Please type or print) Phone <br />b Third Pa Pa ers <br />1 Medicaid tle XIX <br />2 Medicare itle XVIII Signature of Authorized Official Date <br />3 CHIP <br />4 Other Publlc Hlth Insurance Jay T. Kintna/Pcnseaitirg At <br />5 Private Hlth Insurance Nartte and Title (Please type or print) <br />Total- Third Pa Pa ers <br />c Other Revenue <br />1 Local Government For State Agency Use Only <br />2 Other S eci : <br />Total • Other Revenue <br />TOTAL REVENUE Signature of Reviewer Date <br />