Budget and Budget Narrative - PTE-3

OMB Control No:	0970-0474
Expiration Date:
Estimated Burden:	60 minutes

U.S. REPATRIATION PROGRAM
ANNUAL BUDGET AND BUDGET NARRATIVE

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to determine eligibility for temporary assistance under the U.S. Repatriation Program during an emergency repatriation. Public reporting burden for this collection of information is estimated to average 1.0 hours per respondent, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This collection of information is required to obtain a benefit (42 U.S.C. Section 1313). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0474 and the expiration date is xx/xx/xxxx. If you have any comments on this collection of information, please contact the U.S. Repatriation Program, 330 C St. SW, Washington, D.C. 20201.

SECTION I: STATE AND AGENCY NAME
1. State Name	2. Agency Name
SECTION II: ANNUAL BUDGET PERIOD
3. Federal Fiscal Year (MM/DD/YYYY to MM/DD/YYYY) _______________ to _______________
SECTION III: BUDGET AND BUDGET NARRATIVE
4. Personnel
Total Personnel Costs $
Justification
5. Fringe Benefits
Total Fringe Benefits Costs $
Justification
6. Travel
Total Travel Costs $
Justification
7. Equipment
Total Equipment Costs $
Justification
8. Supplies
Total Supplies Costs $
Justification
9. Contractual
Total Contractual Costs $
Justification
10. Other
Total Other Costs $
Justification
11. Direct Charges
Total Direct Charges Costs $
12. Indirect Charges
Total Indirect Charges Costs $
13. TOTAL
Total Direct and Indirect $

GENERAL INFORMATION

Purpose: This form is to provide a budget and budget narrative for planned activities for each annual workplan regarding planning, training, and exercises for repatriation.

Who Should Complete this Form: An official authorized by the state.

When to Submit: Submit with initial application and subsequent annual workplans.

Where to Submit: Submit to OHSEPR-Grants@acf.hhs.gov.

SPECIFIC INSTRUCTIONS

SECTION I: STATE AND AGENCY NAME

Item 1. State Name. Provide the name of the state.

Item 2. Agency Name. Provide the full name of the state agency and relevant office.

SECTION II: BUDGET PERIOD

Item 3. Annual Budget Period (MM/DD/YYYY to MM/DD/YYYY). Enter the beginning and end dates for the budget period for this narrative (e.g., federal fiscal year).

SECTION III: BUDGET AND BUDGET NARRATIVE

All budget categories below align with SF-424A, Budget Information for Non-Construction Programs. See SF-424A Instructions for definitions. Additionally, see the Planning, Training, and Exercises Information Memorandum (OHSEPR-IM-2023-01) for descriptions of activities and allowable costs. All budget costs must be related to the annual workplan (Form PTE-2).

Item 4. Personnel.

Total Personnel Costs. Provide the total amount of personnel costs.

Justification. Describe how the costs are derived. Indicate how the costs support specific annual workplan activities (e.g., 0.5 FTE to support Activity #1 – Plan Revision and Activity #3 – Tabletop Exercise Planning).

Item 5. Fringe Benefits.

Total Fringe Benefits Costs. Provide the total amount of fringe benefits costs.

Justification. For the personnel identified in Item 4, provide the total fringe rate and the calculations for total fringe costs.

Item 6. Travel.

Total Travel Costs. Provide the total amount of travel costs.

Justification. Describe how the costs are derived. Indicate how the costs support specific annual workplan activities (e.g., 1 night hotel for 10 individuals at $200 each = $2,000 to support Activity #2 – Full Scale Exercise).

Item 7. Equipment.

Total Equipment Costs. Provide the total amount of equipment costs.

Justification. Describe how the costs are derived. Indicate how the costs support specific annual workplan activities (e.g., two (2) Equipment X rental cost at $5,500/each = $11,000 to support Activity #4 – Full Scale Exercise.

Item 8. Supplies.

Total Supplies Costs. Provide the total amount of supplies costs.

Justification. Describe how the costs are derived. Indicate how the costs support specific annual workplan activities (e.g., four (4) projectors at $400/each = $1,600 to support Activity #1 – Training and Activity #3 – Tabletop Exercise Planning).

Item 9. Contractual.

Total Contractual Costs. Provide the total amount of contractual costs.

Justification. Describe how the costs are derived. Indicate how the costs support specific annual workplan activities (e.g., planning support contract at $100,000 to support Activity #1 – Plan Revision and Activity #3 – Tabletop Exercise Planning).

Item 10. Other.

Total Other Costs. Provide the total amount of other costs.

Justification. Describe how the costs are derived. Indicate how the costs support specific annual workplan activities (e.g., two (2) state personnel attending conference with fee of $500/each = $1,000 to support Activity #1 – Training.

Item 11. Direct Charges. The sum of Total Costs for Items 4 through 10.

Item 12. Indirect Charges. Enter the amount of indirect cost in accordance with HHS-approved indirect cost rate agreement or the de minimis rate of 10%.

Item 13. TOTAL. The sum of Items 11 and 12.

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