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DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 t A - continued
<br /> Provider's Outside Agency Application
<br /> MAIN APPLICATION
<br /> Section III. Program Information
<br /> Program Budget Worksheet
<br /> AGENCY NAME: Mental Health America of the Triangle-Programs:FAN
<br /> Actual Estimated 2015- Projected 2016-
<br /> PROGRAM REVENUE 2014-15 16 17 Percent Change
<br /> Private Donations $ 18,000 $ 1,400 -100%
<br /> Program Generated Revenue(fees) $ - 0
<br /> Local Government Grants:
<br /> Orange County $ 5,000 0
<br /> Town of Chapel Hill $ 2,000 $ 1,000 $ 2,000 100%
<br /> Town of Carrboro $ 2,000 $ 1,000 $ 2,000 100%
<br /> Other Local: Orange County-JCPC Match $ 12,217 $ 12,217 $ 12,217 0%
<br /> Other Local: Durham County $ 18,979 $ 5,088 $ 5,088 0%
<br /> Other Local: Durham County JCPC $ - $ 14,000 $ 14,000 0%
<br /> If more than 3 sources,please
<br /> provide a separate list.
<br /> Non-Local Government Grants
<br /> Triangle United Way 0
<br /> State Government:JCPC-Orange $ 40,722 $ 40,722 $ 40,722 0%
<br /> Federal Government 0
<br /> Other Grants: Cardinal Innovations $ 49,000 $ 49,000 $ 49,000 0%
<br /> Other Grants: V` 0
<br /> Miscellaneous/Other Revenue $ - $ - $ - 0
<br /> Please list 3 largest Miscellanous sources:
<br /> $ -
<br /> Total Program Revenue $ 142 918 $ 124 427 $ 130 027 5%
<br /> PROGRAM EXPENSES
<br /> Compensation $ 116,624 $ 89,656 $ 102,010 14%
<br /> Rent&Utilities $ 7,551 $ 6,492 $ 6,500 0%
<br /> Supplies&Equipment $ 4,221 $ 3,033 $ 4,230 39%
<br /> Travel&Training $ 4,679 $ 3,632 $ 3,512 -3%
<br /> Other Expenses: $ 11565 $ 13,153 $ 13,625 4%
<br /> Please list 3 largest"Other Expenses":
<br /> Contractual Services $ 6,450
<br /> Insurance $ 4,265
<br /> Dues,Bank,Adv $ 850
<br /> Total Program Expenses $ 144,640 $ 115,967 $ 129,877 12%
<br /> SURPLUS/(DEFICIT)FOR PERIOD: $ (1,722)1 $ 8,461 1 $ 150 1 -98%
<br /> Main Application 5/25/2016 9:20:28 AM H '7 0 f 2
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