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12 <br /> 2of7 <br /> Part III - Distribution of Estimated Revenue for Total Cost Reimbursement Method <br /> (a) <br /> A. Estimated Eligible and Matchable Costs Numb (b) <br /> er Ratio <br /> 1 . Estimated Eligible Clients 13 100 <br /> 2. Estimated Ineligible Clients <br /> 3. Total Clients 13 100 <br /> B. Eligible Costs <br /> (1 ) Matchable (2) Less (3) Net <br /> (4) - (51 Costs Eligible i <br /> Costs Earned Matchable Estimated for Financial <br /> [Part I, Line M, Income Costs of Eligibles Participation <br /> col . (3)1 [B. (1 ) Less (2)] [A. 1 . (b)] [B. (3) x (4)1 <br /> 32,500 $ -0- S 32,500 100% : S32,500 .I <br /> .. <br /> Part IV - Additional Revenue and Fees • <br /> A. Program Costs Amount Source of Funds <br /> 1 . Federal/State Funds $ 32.500 JOBS <br /> 2. Local Matching Share <br /> 3. Other Budgeted Funds $ -n- <br /> 4. TOTAL REVENUE <br /> • <br /> 5-- 32,500 <br /> B. Fees (If Applicable) <br /> 1 . Administrative Fee $ -0- <br /> 2. Certification Fee <br /> 1 <br /> 3. TOTAL FEES $ 0- <br /> i <br /> Part V - Reimbursement Projections (For Title XX Providers Only) <br /> July-September October-June <br /> Annual Projection Projection , <br /> 1 <br /> A. S <br /> Signed: ,/" dr ��/111W- 0 _3 Date:Prov1Cer/Autho iz-./lfficial <br /> 0(A(2-#(1.A._,J 7 0 -' Date: r2 A3 <br /> County rect3r/or 3esignee <br /> OSS-6244 (2/E3) <br /> Family Services <br />