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FORM 1: FUNDING REQUEST BUDGET PAGE <br />All respondents must complete this budget page to detail the use of funds requested. Each item on this budget page must be supported <br />in your proposal narrative, FORM H: WORK PLAN. Also refer to Section II, F. Funding Preferences and Limits. <br />*You may indicate the importance of your items by placing a priority number by each item (see Examples below). On FORM H: WORK <br />PLAN, explain how you determined your priority. Refer to Form G: Work Plan Guidelines, 4. Budget. <br />Use additional pages as needed. <br />If submitting a multiple entity proposal, submit a separate page for each entity for which funds are requested. <br />Name of entity: <br />Equipment and Supply Items: <br />Any individual item with a useful life of more than one year <br />and a cost of more than $1, 000 (including shipping) requires <br />50% matching funds. Please be very descriptive when listing <br />your items (e.g. make/brand, model number, year, etc.) <br /> <br /> <br /> <br />n X <br />Oww <br />UO.L: <br /> <br />U <br /> <br />?- <br />zQwW <br />w20.? <br /> <br />z <br />N p <br />_ 0 Of <br />rn0LL w <br />00-00. <br /> <br />z <br /> <br />Q <br />0 <br />a <br /> <br />c i c? <br />? a o <br />0 0? z <br />uJ 0D <br />WU- U- <br />EXAMPLE ONLY: *Priority 1-12 Lead Monitor/Defibrillator <br />with batteries and carrying case <br />$17,000 <br />$9,500 <br />$7,500 <br />2 <br />$15,000 <br />EXAMPLE ONLY: *Priority 1- Ferno scoopstretcher, Model <br />65 <br />$500 None <br />Required <br />$500 <br />1 <br />$500 <br />EXAMPLE ONLY: *Priority 2- Pediatric Advanced Life <br />Support Trainer with replacement skin and vein <br />$4,700 <br />$2,350 <br />$2,350 <br />2 <br />$4,700 <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />Fax machines, stereo equipment, cameras, video <br />recorder/systems and computer/related equipment <br />(Requires a 50% match if the individual items cost exceeds <br />$500 and the useful life is greater than one year). If <br />requesting funds for computers, see Form J: Minimum <br />Computer Specifications Form <br /> <br /> <br />Other Expenses (Education/Training, injury prevention, etc.): None <br />required <br /> <br /> <br /> <br />TOTAL FUNDING REQUESTED ON THIS PAGE: <br />Page 38 RFP# EMS/LPG - 0328.1