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DocuSign Envelope ID:A13A145D-D67A-4FF7-ABA9-312E380D8DD9 <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 /> 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 /> • Audit- $4,600 <br /> • Fundraising - $4,793 <br /> • Workers compensation insurance - $5,163 <br /> • Liability insurance - $3,381 <br /> • Youth activities - $2,263 <br /> • Girls group coordinator- $3,000 <br /> • IT and graphic design support- $920 <br /> • Internet - $1,275 <br /> • Repairs & maintenance - $982 <br /> • Restitution payments- $2,467 <br /> • Volunteer training and support- $877 <br /> • Professional development- $1,113 <br /> 3. This program budget represents what percent of the agency budget? 100% <br /> 4. COST PER INDIVIDUAL <br /> PROGRAM INFORMATION 2/8/2017 10:03:24 AM F' a g e 19 90 22 <br />