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DocuSign Envelope ID: E865EBC7-DCBB-4CE6-A224-13D663E29E12 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 74,'"////4 y%� ��°'%//%% J, e„ i�,, i/ C//4� r�« a r , ri <br /> /,; f ,�,„ /foO'6� bra' III fif r w „ r a4 41')674� /f� ' , 1/%> <br /> Total Cost of Program $214,292 $206,718 $214,983 <br /> Total #of Individuals 4620 4620 4620 <br /> �. .� .. .�..�.__$44.73 .._...�. <br /> Cost Per Individual $46.28 $46.53 <br /> I <br /> PROGRAM INFORMATION 1/30/2017 4:02:21 PM 1114age 46 of <br />