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DocuSign Envelope ID:2A83AE93-E43A-4DCA-8002-FA0D789204A6 <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 /> 0 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 budget items include membership fees to our national database management <br /> system; fundraising costs; agency insurance; and background checks. <br /> 3. This program budget represents what percent of the agency budget? 72% <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 /> l',/,Y/;*:.4*/167/;1,6,; /414001//g01047'ZIOii**040:1:744 <br /> Total Cost of Program $675,350 $748,000 $768,000 <br /> Total # of Individuals 1068 1030 1100 <br /> Cost Per Individual $632 $726 $698 <br /> PROGRAM INFORMATION 1/27/2017 1:43:18 PM Page 21 of 24 <br />