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Part III- Distribution 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)1] A. 1. B. 3 x(4 <br /> $ $ $ $ $ <br /> A. Program Costs Amount Source of Funds <br /> 1. Federal/State Funds $ 39,865.00 Work First Program <br /> 2. Local Matching Share $ <br /> 3. Other Budgeted Funds $ <br /> 4. TOTAL REVENUE $ 39,865.00 <br /> 7. Fees( If Applicable) <br /> 1. Administrative Fee $ <br /> 2. Certification Fee $ <br /> 3. TOTAL FEES $ <br /> Part V-Reimbursement Projections(For Title XX Providers Only) <br /> Annual Projection July- September October-June <br /> Projection Projection <br /> A. $ B. $ C. $ <br /> Signed: + - Date: �L �- <br /> Provider/Authorized Official <br /> Date: <br /> County Director or Designee <br />