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Agency Name <br />• . : MeMl M I V• <br />-. 1 �'•• • <br />Administrative Support Wo rksheet <br />F 212A <br />1. Administrative Support requested for (Name of Grant): <br />2. Total amount of Administrative Support requested: $ <br />3. Brief description of grant including the name of the funding source: <br />4. Total Grant Amount: <br />$ <br />5. Give the reason for requesting Administrative Support from CSBG and describe how the funds will <br />be used: (Attach supporting documentation in the Appendices) <br />6. How will the agency track the CSBG funds used for Administrative Support? <br />7. Basis for determining amount of Administrative Support needed. <br />(Please select either Indirect Costs or Cost Allocation, not both.) <br />Indirect Costs <br />Indirect Cost Base <br />Indirect Cost Rate %: <br />% <br />Indirect cost base amount for this grant: <br />$ <br />Percent indirect allowed by funding source for this <br />grant: <br />% <br />Dollar amount indirect allowed by funding source for <br />this grant: <br />$ <br />Cost Allocation <br />Percent of administrative costs allowed by funding <br />source for this grant %: <br />% <br />Dollar amount of administrative costs allowed by <br />funding source for this grant: <br />$ <br />8. Actual numerical calculation used to <br />determine Administrative Support needed: <br />9. Administrative Support to be applied: <br />(choose one) <br />Monthly <br />Quarterly <br />Annually <br />Fiscal Year 2013 -14 Community Services Block Grant Application <br />Page 28 of 42 <br />Attachment number 3 <br />F -6 Page 92 <br />