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Part III -Distribution of Estimated Revenue for Total Cost Reimbursement Method <br />(a) ro) <br />A. Estimated Eligible and Matchable Costs Number Ratio <br />1. Estimated Eligible Clients 16 <br />2. Estimated ineligible Clients <br />3. Total Clients <br />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 <br />1. FederaUState Funds <br />2. Local Matching Share <br />3. Other Budgeted Funds <br />4. TOTAL REVENUE <br />Amount Source of Funds <br />$ 39.682.01 Work First Proms <br /> <br /> <br />$ 39.682.01 <br />7. Fees (If Applicable) <br />1. Administrative Fee <br />2. Certification Fee <br />3. TOTAL FEES <br /> <br /> <br /> <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 />Provi / uthorized fficial <br />o ty ector or Designee <br />Date: ~P - ~ ~ '~ 3 <br />Date: ~/' ~~ <br />