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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 /> Program: Ada•ted S•orts: Boccia Ball <br /> Cost Elements Cost($) Quantity/Unit of measure Subtotal ($) <br /> Program Coordinator $25 Cost/Hour/$25 (96hrx$25) $2,400 <br /> Equipment Storage Rent Cost $150 Equipment x 1 programs $150 <br /> Travel $.575/mile 1,268 x .575/mile $729 <br /> Printing, equip. maintenance, admin, etc $9,399 $9,399 x 1 program $9,399 <br /> Total $12,678 <br /> d.) Cost per Unit <br /> Actual 2014-15 Estimated 2015-16 Projected 2016-17 <br /> Total Cost of Program $8,750 $12,678 $12,678 <br /> Total # of Units 66 105 160 <br /> Cost Per Unit $132.58 $120.74 $79.24 <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 25 of 2 <br />