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DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <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 /> Please refer to the attachment titled "BITS Agency and Program Budgets" to view the <br /> boccia program budget. <br /> 2. Program Budget Detail — Provide description of "other" budget items, not defined. <br /> We do not have "other" budget items provided in our boccia program budget. <br /> 3. This program budget represents what percent of the agency budget? 1.7% <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 /> Actual 2015-16 Estimated 2016-17 Projected 2017-18 <br /> Total Cost of Program $15200 $15960 $16758 <br /> Total # of Individuals 239 251 264 <br /> Cost Per Individual $64 $64 $63 <br /> PROGRAM INFORMATION 1/27/2017 3:48:29 PM P g c 1G of 2G <br />