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DocuSign Envelope ID: 1632E805-38D3-49DF-9836-981006B20F64 XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <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/HOMEletc,) <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 /> a Other Expenses <br /> This program budget represents what percent of the agency budget? 100 <br /> 2. 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- <br /> 18 <br /> Total Cost of <br /> nia <br /> Program <br /> Total # of <br /> Individuals <br /> Cost Per <br /> Individual <br /> PROGRAM INFORMATION 1/31/2017 4:15:48 PM P a g e 19 of 22 <br />