Office of the Assistant Secretary
Divisions of Alcohol and Substance Abuse, Developmental Disabilities, Family and Community Services, Mental Health, and Rehabilitation Services

Maximizing Accountability and Excellence Initiative (FY15)

Request for Proposal for Title XX and DFI - Services for DHS Open Door Program

Attachment C - Budget Forms (Instructions & Forms)

Contract Number:

Document Number:

(To be completed by DHS)


2015 Program Plan Summary Questions Response
1.  Agency Name:
2.  Agency Address:
3.  Remittance Address:
4.  Agency Head and Title / Telephone / Email Address (Required):
5.  Program Contact Person and Title / Telephone / Email Address (Required):
6.  Fiscal Contact Person and Title / Telephone / Email Address (Required):
7.  Fax Number:
8.  Tax Payer I.D. Number:
9.  Title XX Social Services Block Grant Services Category:
10:  Identify Geographic Service Area for DFI Program (e.g., neighborhood, city, county):
11.  Identify the target population to be served by the DFI program (e.g., women, men, children, age groups):
12.  Identify the location(s) at which service provision will occur:
13.  A.  Total Funds Requested from IDHS:
13.  B.  Local 25% Required Match (Match may be all cash or a combination of cash and In-kind) no less than 10% cash and up to 15% In-kind Match Cash + In-kind:
13.  C.  Total DFI Program Budget ( A + B):
13.  D.  Identify amount and source(s) of Cash Match:
13.  E.  Identify amount and source(s) of In-kind Match:

14.  Identify your Congressional District (by number):

Identify your Illinois Senate District (by number):

Identify your Illinois House District (by number):

15.  Identify your local IDHS office(s) that you link with, by name and number:

FY15 Title XX Donated Funds Initiative Budget (Include 25% match)

Line Items




Program Services



A. Personal Services:  (attach Narrative)
Salaries $0 $0 $0
Payroll Taxes and Fringe Benefits $0 $0 $0
Contractual $0 $0 $0
B.  Consumables:  (attach Narrative)
Supplies $0 $0 $0
Printing $0 $0 $0
Postage $0 $0 $0
C. Occupancy:
Rent $0 $0 $0
Utilities $0 $0 $0
Building Maintenance $0 $0 $0
Telephone $0 $0 $0
D.  Miscellaneous:
Staff Travel $0 $0 $0
Equipment Maintenance $0 $0 $0
Depreciation $0 $0 $0
Conferences, Meetings $0 $0 $0
Liability / Other Insurance $0 $0 $0
Management / General $0 $0 $0
E. Other (Specify):
Client Subsidies $0 $0 $0
Computer and Software $0 $0 $0
TOTAL $0 $0 $0

Administrative Cost Percentage

To calculate the administrative cost percentage, divide the total administrative costs, Column A, by the total program services costs, Column B:

Grand Total of Column A/Grand Total of Column B then multiple 100 = % No more than 20%.

Reimbursement is not available for purchase of fixed equipment more than $1,000. Typical examples for administrative/indirect are administrative personnel, rent, utilities, building maintenance, local telephone, equipment maintenance, management and general and accounting. For purposes of this program, it is requested that direct costs be those directly associated with the delivery of program services. These may include labor, program supplies, space for services, etc. Classification of costs are subject to interpretation by the Department. Federal Circulars can be referenced for assistance: OMB Circular A-21, "Cost Principles for Educational Institutions" A-87 "Cost Principles for State, Local Governments", A-122 "Cost Principles for Non-Profit Organizations."

Title XX Donated Funds Initiative Budget

Salary Details







Program Services




The TOTAL figures must match those reported on line A, Personal Services: Salaries on previous page. Do not include payroll taxes, fringe benefits, or contractual. For each position, enter the full-time equivalency (FTE) for that position.  An FTE of 1.0 means that the position is equivalent to a full-time worker.  An FTE of 0.5 indicates that the worker is only half-time. Note: There should be a correlation between the number of FTE's budgeted for direct service and quantity of service hours to be delivered. In other words, amounts that are billed should be proportionate to the services delivered, as the program is fee for service.


Provide a budget narrative for each line item of the budget. Any package received without a budget narrative will be returned to the Provider.

Each line item must have a narrative explanation or justification stating the method used in determining the amount allocated to each line item, why and how funds are to be utilized. Include your basis for determining administrative/indirect and direct program services. For assistance in determining administrative/indirect versus direct cost components, please consult either OMB Circular A-21 Cost Principles for Educational Institutions, OMB Circular A-87 "Cost Principles for State, Local and Indian Tribal Governments" or OMB Circular A-122 "Cost Principles for Non-Profit Organizations." Specifically identify the components of each line item. For larger line items, a separate schedule may be used to provide a breakout. A budget submitted without narrative explanation or justification of each line item will be considered incomplete.

Note: While it is permissible for more than one funding source to share the costs of a given service, it is not permissible for two funding sources both to reimburse the same cost of a service. Double claiming is prohibited even if the combined sources do not exceed the expenditures.

  • Personal Services: (Attach Narrative)
  • Salaries:
  • Payroll Taxes and Fringe Benefits: A separate budget allocation is unnecessary because payroll taxes and fringe benefits are included in the 15% administrative fee paid to the University.
  • Contractual  None
  • Consumables: (Attach Narrative)
  • Supplies:
  • Printing:
  • Postage:
  • Occupancy: (Attach Narrative)
  • Miscellaneous: (Attach Narrative)
  • Staff Travel:
  • Equipment Maintenance:
  • Depreciation:
  • Conferences, Meetings:
  • Liability/Other Insurance:
  • Insurance:
  • Management/General: (Attach a separate sheet to break out)
  • Other (Specify): (Attach Narrative)