Form A: PROJECT BUDGET INSTRUCTION: This form is to be completed if capital expenditures will be necessary for the applicant hospital to provide pPCI services. All estimates for 1.a.-d., 2.a.-h., and 3 are for current as of the date of application submission and should include the costs for all intended construction and renovations to be undertaken. DO NOT CHANGE THIS FORM OR ITS LINE ITEMS. IF ADDITIONAL DETAIL OR CLARIFICATION IS NEEDED, ATTACH ADDITIONAL SHEETS. A. Use of Funds 1. Capital a. New Construction $ ___________ (1) Building ___________ (2) Fixed Equipment (not included in construction) ___________ (3) Land Purchase ___________ (4) Site Preparation ___________ (5) Architect/Engineering Fees ___________ (6) Permits, (Building, Utilities, Etc) ___________ $ ___________ SUBTOTAL b. Renovations (1) Building $ ___________ (2) Fixed Equipment (not included in construction) ___________ (3) Architect/Engineering Fees ___________ (4) Permits, (Building, Utilities, Etc.) ___________ SUBTOTAL $ ___________ c. Other Capital Costs (1) Major Movable Equipment ___________ (2) Minor Movable Equipment ___________ (3) Contingencies ___________
Form A: PROJECT BUDGET INSTRUCTION: This form is to be completed if capital expenditures will be necessary for the applicant hospital to provide pPCI services. All estimates for 1.a.-d., 2.a.-h., and 3 are for current as of the date of application submission and should include the costs for all intended construction and renovations to be undertaken. DO NOT CHANGE THIS FORM OR ITS LINE ITEMS. IF ADDITIONAL DETAIL OR CLARIFICATION IS NEEDED, ATTACH ADDITIONAL SHEETS. A. Use of Funds 1. Capital a. New Construction $ ___________ (1) Building ___________ (2) Fixed Equipment (not included in construction) ___________ (3) Land Purchase ___________ (4) Site Preparation ___________ (5) Architect/Engineering Fees ___________ (6) Permits, (Building, Utilities, Etc) ___________ SUBTOTAL $ ___________ b. Renovations (1) Building $ ___________ (2) Fixed Equipment (not included in construction) ___________ (3) Architect/Engineering Fees ___________ (4) Permits, (Building, Utilities, Etc.) ___________ SUBTOTAL $ ___________ c. Other Capital Costs (1) Major Movable Equipment ___________ (2) Minor Movable Equipment ___________ (3) Contingencies ___________
con_combined_primary_elective_pci_application201500904.docx