American Speech-Language-Hearing Association

ASHA Reimbursement Issues Grants: Budget Proposal Form

Please complete the funding proposal for your project for both expenses where ASHA funding will be used and expenses where state funds will be used. Please indicate not applicable with N/A.

Note: Receipts will be required for expenses incurred as well as completion of an expense report that will be provided.

*indicates required field.

 

Project Title:*

 

Proposed Human Resource Expenses

  ASHA Funds State Association Funds

Salary of Staff:*

Fringe Benefits:*

Contractual:*

Lobbyist:*

Other (please specify):*

Total Human Resources:*

Other Resources/Proposed Expenses

  ASHA Funds State Association Funds

Travel:*

Meals:*

Equipment:*

Supplies:*

Reproduction/Printing:*

Telephone:*

Postage/Shipping:*

Publicity:*

Other (please specify):*

Total Other Resources:*

Combined Total Expenses:*

President's Affirmation

The insertion of my name below is proof that I am the president of this association and can attest to the validity of the information contained in the Budget Proposal.

President's Name:*

 

State Association:*

 

E-mail:*

 

Today's Date (MM/DD/YYYY):*

 

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