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DocuSign Envelope ID: E865EBC7-DCBB-4CE6-A224-13D663E29E12 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> n) Program Budget-Domestic Violence <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 /> Other Revenue: <br /> Please list 3 largest Miscellaneous sources: <br /> Art Show $ 18,930 <br /> Special Events $ 3,714 <br /> APPLES Inter UNC $ 776 <br /> Other Expenses: <br /> Please list 3 largest"Other Expenses": <br /> Contracted Services $ 23,926 <br /> Telephone Systems $ 4,003 <br /> Art Show $ 3,318 <br /> 3. This program budget represents what percent of the agency budget? 39.2% <br /> 4. COST PER INDIVIDUAL <br /> This Cost per Individual must reflect the total program budget divided by the total number of <br /> program individuals in this application. <br /> PROGRAM INFORMATION 1/30/2017 4:02:21 PM Page,g ,, 2 2 of 4 <br />