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DocuSign Envelope ID:4D553CF7-2BBD-4F4E-B84E-E6B8B077A9AB <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> m) 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 /> • Revenues <br /> O Private Donations <br /> O Program Generated Revenue <br /> O Local Government Grants <br /> • Carrboro Human Services <br /> • Carrboro Other <br /> • Chapel Hill Human Services <br /> • Chapel Hill Other(DO NOT include CDBG funding here) <br /> • Orange County Human Services <br /> • Orange County Other(DO NOT Include HOME funding here) <br /> O Other Government Grants <br /> • Triangle United Way <br /> • State Government <br /> • Federal Government(CDBG/HOME/etc.) <br /> • Private Foundation Grants <br /> O Other Revenue <br /> • Expenditures <br /> O Compensation <br /> O Rent & Utilities <br /> O Supplies & Equipment <br /> O Travel &Training <br /> O Other Expenses <br /> 2. Program Budget Detail— Provide description of"other" budget items, not defined. <br /> Our projected numbers served show a much larger increase because we are including <br /> clients who utilize our walk-in crisis services which we were not capturing in our reporting <br /> totals before (FY15-16). Projected numbers for FY17-18 are also capturing UNC IV port <br /> clients which skews the Cost per Individual. This partnership will generate additional <br /> funding for the crisis services. <br /> 3. This program budget represents what percent of the agency budget? 21.94% <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 /> ;Actual,;2015-16 Estimated 2016-17 Projected 2017-18 ,3 <br /> Total Cost of Program $2,133,028 $2,549,910 $2,539,428 <br /> Total # of Individuals 2,064 2,639 3,349 <br /> Cost Per Individual $1,033.44 $966.24 $758.26 <br /> DO NOT SUBMIT THIS PAGE 1/31/2017 1:07:36 PM Page 1 7 of 37 <br />