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E (919) 385-3100 Fax (919) 385-3103 BUDGET AND INFORMATION FORM BROAD EXTRAMURAL AWARD: Applicant name: Institution: Mailing address: City: Email address: Staff Name Role in Project State: Phone number ( Salary Fringe Benefits Zip Code: ) Year 1 Total Year 2 Total Equipment: Supplies: Other: Subtotal: Indirect Cost: (maximum allowable is 10% of award) $ $ $115,000 $115,000 TOTAL Award period: July 1, 2012 June 30, 2014 Application deadline: February 1, 2012 Please submit pro.

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