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' pair iii - T~i~trihution of Estimated Revenue for Total Cost Reimbursement Method <br />(a) (b) <br />A. Estimated Eligible and Matchable Costs Number Ratio <br />1. Estimated Eligible Clients 16 <br />2. Estimated ineligible Clients <br />3. Total Clients 16 <br />B. Eligible Costs <br />(1) Matchable (2) Less (3) Net (4) (5) Costs Eligible <br />Costs Earned Matchable Estimated % for Financial <br />[Part 1, Line M, Income Costs of Eligible Participation <br />col. (3) [B. (1) Less (2)}] [A. I. (b)] [B. (3) x (4)] <br />$ $ $ $ $ <br />A. Program Costs <br />1. Federal/State Funds <br />2. Local Matching Share <br />3. Other Budgeted Funds <br />4. TOTAL REVENUE <br />7. Fees (If Applicable) <br />1. Administrative Fee <br />2. Certification Fee <br />3. TOTAL FEES <br />Amount Source of Funds <br />$ .46.766.51 Work First Program <br /> <br />$ 46,766.51 <br />Part V-Reimbursement Projections~For Title XX Providers Only) <br />Annual Projection July- September <br />Projection October-June <br />Projection <br />A.$ B.$ C.$ <br />Signed: <br />Pro Authorized fficial <br />ounty erector or Designee <br />Date: '7 S-n t„ <br />--~ '~ <br />Date: 7~wG <br />