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' (a) (b) <br />Estimated Eligible and Matchable Costs Number Ratio <br />1. Estimated Eligible Clients 16 <br />2. Estimated ineligible Clients 0 <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. 3 x 4 <br />$ $ $ $ $ <br />A. Program Costs <br />1. FederaUState Funds $ 47,505.00 <br />2. Local Matching Share $ <br />3. Other Budgeted Funds $ <br />Source of Funds <br />Amount <br />TANF Block Grant <br />4. TOTAL REVENUE $ 47.505.00 <br />B. Fees (If Applicable) <br />1. Administrative Fee $ 0 <br />2. Certification Fee $ 0 <br />3. TOTAL FEES $ ~ <br />Part V-Reimbursement Projections fFor Title XX Providers Only) <br />Annual Projection July- September - <br />Pro'ection October-June <br />Pro'ection <br />A. $ B. $ C. $ <br />tea. Signed: ~~~~/v/ <br />Provider/Au orized Official <br />"C6unt ~ ~r~ r~or Designee ~~ <br />Y <br />Date: ..~''z7 ~~ ~ <br />Date: ,`f~L/~y <br /> <br />