Ill. Admin. Code tit. 77, § 635.APPENDIX C
Checklist for Completing the FY90
Family Planning Services Application
Check ( ) the following item for completeness before submitting your application for processing. Each must be addressed, filled in or attached as indicated. CHECKLIST MUST BE SUBMITTED WITH APPLICATION.
| Cover Sheet Attachment A | ||||
| Complete Sections | 2 | Applicant Organization | ||
| 3 | Applicant Certification | |||
| 4 | Type of Organization | |||
| 5 | Grant Support Requested | |||
| 6 | Type of Application | |||
| 7 | Legislative District | |||
| 8 | Date of Submission | |||
| Health Care Plan | ||||
| #10 complete narrative | ||||
| #11 define target area | ||||
| #12 list clinic(s) names(s) | ||||
| and days/hours of operation | ||||
| #13 complete budget in accordance | ||||
| with the attached budget and | ||||
| expenditures category definitions | ||||
| Checklist – FY 90 | ||||
| #14 complete cost analysis by IDPH methodology | ||||
| Between Page 5 & 6 attach schedule of discounts | ||||
| and sliding fee scale with charges based upon | ||||
| 1989 Poverty Guidelines. | ||||
| #15 complete three (3) objectives | ||||
| Complete attached Plans to Achieve | ||||
| Objective/Program Progress Report | ||||
| Forms three (3) | ||||