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DocuSign Envelope ID: 1007B77C-A009-4AA3-964B-3B03B9585341 <br /> txnibit A-continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> b.) Program Budget Detail <br /> What is the cost to deliver your project/program? List each project/program element in the table below, <br /> including the cost of each element, the quantity and unit of measure, and the subtotal for each element. <br /> Where necessary, allocate costs to the use of shared space, vehicles or equipment. <br /> Example Program: Credit Counseling Class <br /> Cost Elements Cost($) Quantity/Unit of Measure Subtotal($) <br /> Credit Counseling Teacher–in class $25 96 hours (8 hrs/mth x 12 months) $2,400 <br /> Credit Counseling Teacher—class prep $25 48 hours (4hrs/mth x 12 mths) $1,200 <br /> Credit Counselor—one-on-one $20 120 hours (10 hrs/mth x12 mths $2,400 <br /> Materials $25 120 course packets/credit reports $3,000 <br /> Total $9,000 <br /> Complete the table below for the project/program for which you are requesting funds. <br /> Attach additional rows/pages, as needed. <br /> Program: Adapted Sports: Wheelchair Basketball <br /> Cost Elements Cost($) Quantity/Unit of measure Subtotal ($) <br /> Program Coordinator(2) $25 352hr x $25 $8,800 <br /> Equipment Storage Rent Cost $2,998 Equipment x 3 programs $8,994 <br /> Printing, equip. maintenance, admin, etc $28,197 $9,399 x 3 programs $28,197 <br /> Travel $.575 1,344 miles x .575/mile $774 <br /> Total $46,765 <br /> C.) Cost per Unit <br /> Actual 2014-15 Estimated 2015-16 Projected 2016-17 <br /> Total Cost of Program $24,092 $46,591 $46,765 <br /> Total # of Units 222 235 300 <br /> Cost Per Unit $102.52 $198.26 $155.88 <br /> This Cost Per Unit must reflect the total program budget and the total number of <br /> program beneficiaries (households or persons) in this application and must be <br /> consistent with report submittals from previous years (if applicable). <br /> Main Application 5/24/2016 9:03:13 AM P 21 of 2 <br />