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DocuSign Envelope ID:87560079-2786-4376-A189-DC48D9482BE7 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> Performance Measures • <br /> Previous Year Program Results <br /> Current Year Estimated Results <br /> Next Year Projected Results <br /> n) Program Budget <br /> 1. Submit your program budget.You may complete the provided template (separate xls <br /> file)or you may submit your own budget file (as long as it contains the same information, <br /> in the same format, as requested in the provided template). <br /> Program Budgets are required to define budget amounts for the previous program <br /> • year, current program year, and next program year for the following categories: <br /> 2. Program Budget Detail --Provide description of"other" budget items, not defined. <br /> 3. This program budget represents what percent of the agency budget? 18% <br /> Other Expenses: Emergency Funds for Parent Aide clients $50 a family and <br /> operational costs for program implementation. <br /> 4. COST PER INDIVIDUAL <br /> This Cost per Individual must reflect the total program budget divided by the total number of program <br /> individuals in this application. <br /> 3�b �.. �l"� 4 `3� .vii �`?i�,�� a F�s-Kr`� . �'.ir, a���i��m ,�� �`1�i-1},,�+ r �r� <br /> amm o, ,u �€ ► tiv Q rtrtl. versa cxed� C� 7 _ <br /> Total Cost of Program $9,000 $18,175 $29,700 <br /> Total #of Individuals 25 40 46 <br /> II <br /> Cost Per Individual $360 $454 <br /> $645 <br /> • <br /> • <br /> • <br /> • <br /> ' 1 <br /> PROGRAM INFORMATION 1/27/2017 1:48:20 PM Page 12 of 12 <br />