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Part III -Distribution of Estimated Revenue for Total Cost Reimbursement Method <br />a <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. I. (b J B. (3) x (4) <br />$ $ $ $ $ <br />A. Program Costs <br />Amount <br />Source of Funds <br />1. FederallState Funds $ 46,719 <br />2. Local Matching Share $ <br />3. Other Budgeted Funds $ <br />4. TOTAL REVENUE $ 46,719 <br />B. Fees (If Applicable) <br />1. Administrative Fee $ 0 <br />2. Certification Fee $ 0 <br />3. TOTAL FEES $ ~ <br />TANF Block Grant <br />Part V-Reimbursement Projections CFor Title XX Providers Only) <br />Annual Projection July- September <br />Projection October-June <br />Projection <br />A. $ B. $ C. $ <br />Signed:- ~ ~ Date: ~ <br />rovid r/Authorized cial <br />Date: ~'~Z z ~ 3' <br />o ty ector or Designee <br />