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DocuSign Envelope I D:72266CE5-DF5A-471E-B671-CC65C8960691 <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 /> e 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 /> 3. This program budget represents what percent of the agency budget? 60% <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 $192,775.00 $209,158.00 $202,414 <br /> Total # of Individuals 613 603 644 <br /> Cost Per Individual $314.00 $346.86 $330.00 <br /> PROGRAM INFORMATION 1/25/2017 4:42:59 PM 0002 20 of 22 <br />