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DocuSign Envelope ID:4D553CF7-2BBD-4F4E-B84E-E6B8B077A9AB <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> Program Budget <br /> 9. 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 /> 10. Program Budget Detail — Provide description of"other" budget items, not defined. <br /> 11. This program budget represents what percent of the agency budget? 1.7% <br /> 12. 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 /> Acts 01516 Estimated 2!01617 Projected 01 '-18 <br /> Total Cost of Program $187,199 $202,276 $196,900 <br /> Total # of Individuals 448 508 512 <br /> Cost Per Individual $417.85 $398.18 $384.57 <br /> DO NOT SUBMIT THIS PAGE 1/31/2017 1:06:25 PM Pacie 37 of <br />