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Part III -Distribution of Estimated Revenue for Total Cost Reimbursement Method <br />(a) ~) <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. 1. b [B. 3 x 4 ] <br />$ $ $ $ $ <br />A. Program Costs Amount Source of Funds <br />1. FederaUState Funds <br />2. Local Matching Share <br />3. Other Budgeted Funds <br />4. TOTAL REVENUE <br />$ 44,322.53 Work First Prog am <br /> <br /> <br />$ 44,322.53 <br />7. Fees (If Applicable) <br />1. Administrative Fee <br />2. Certification Fee <br />3. TOTAL FEES <br /> <br /> <br /> <br />Part V-Reimbursement Protections (For Title XX Providers Onlv) <br />Annual Projection July- September <br />Pro'ection October-June <br />Pro'ection <br />A. $ B. $ C. $ <br />Signed: <br />rovi r/Autho ' e icial <br />o ty rector or esignee <br />Date: S r 3~ <br />Dater ~t`~/ /aj~ <br />