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DocuSign Envelope ID:60192208-BFA3-4E38-9277-B2390FDDC97D <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 xis <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 /> • Liability insurance <br /> • Contract facilitators— Facilitators of all three programs are paid hourly on a <br /> contractual basis <br /> • Contract bookkeeper—Maintains financial records, provides financial reports, <br /> etc. <br /> 3. This program budget represents what percent of the agency budget? 100% <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 /> ��I�It ININIIp 1111,1.„III II N I ,,J I I ,,i V hI'I��Ip,�I•li.' 1!"�MINI I. nq.u11��,., � I INI,'+9!Ni1If f i'y...l II p.�.r�im�1. :1 III9.I;I:,,� �I <br /> II�IIIt'I�II.�I11��1�11 1 I�1 11111.1!Illl�l �IIIIIIIII,�1IIrI�I,�IryryI I�II�� �11,, 11 III III,; II...II� 1 �.� m'"� ":,F1.,.I .III It I I: q 1 ����I16.,.��.1y111 II 1 I� II I1� 'IIV u 1 <br /> Ih�RIIII I{III i1:II;i11 u p I .. 1 1I 111611 III Il 1�i�ll6l„ II 119 ,..: 1 1 ,.1 I, L 1 "`,II 21 1 I �j1 1 I I�i.:.1�r111 11. 8 <br /> )�I661N,II,III1111i1 11!,x.111I III !IIII II II IIII II IFFIIIII�I�iI111�lUII III�1 � (� Illlf� ��lli�ifli't, (Ih�l� "I uy X11111 IIII��IIIII I � 11 11 h II I, <br /> Total Cost of Program 0 $52,741 $104,500 <br /> Total # of Individuals 0 8 122 <br /> Cost Per Individual 0 $6,593 $857 <br /> PROGRAM INFORMATION 1/30/2017 10:59:56 AM Page 19 of 21 <br />