New Jersey Department of Health	SCHEDULE B

APPLICATION FOR GRANT FUNDS	CONSULTANT SERVICES COSTS

Name of Applicant

Proposed Grant Title

Date of Application

List services which provide for program or client benefit and are contracted for on a cost per client, percentage or time, or number of hours basis. Examples of consultant services: accounting, medical, psychological, psychiatric, and other professional services. A copy of individual agreements will be required if an award is made.

Do consultant services demonstrate a true employer / non-employee relationship as per IRS regulations?	Yes	No
IF ADDITIONAL SPACE IS NEEDED, PLEASE USE THE SCHEDULE B FORM THAT IS AVAILABLE ELECTRONICALLY AS AN INDIVIDUAL DOCUMENT.
Nature of

Consultant Service	Basis for Cost

Estimate

(Rate X Time)	Total

Funds

Needed	Grant Funds

Requested

From State	Funds From Other Sources	STATE USE ONLY
TOTAL CONSULTANT

SERVICES COSTS

New Jersey Department of Health	SCHEDULE B

APPLICATION FOR GRANT FUNDS	CONSULTANT SERVICES JUSTIFICATION

Name of Applicant

Proposed Grant Title

Date of Application

List and justify each consultant service in same order as on SCHEDULE B: CONSULTANT SERVICES COSTS.
IF ADDITIONAL SPACE IS NEEDED, PLEASE USE THE SCHEDULE B FORM THAT IS AVAILABLE ELECTRONICALLY AS AN INDIVIDUAL DOCUMENT.
Nature of

Consultant Services	Responsibilities and/or Duties	Minimum Qualifications

(education and experience)

FS-40b

AUG 12	Page 2 of 2 Pages.

FS-40B, schedule B, Consultant Services Costs

FS-40B, schedule b, grant application, grant, consultant, financial services, FS, consultant costs

ewhite

2007-04-09

NJDOH