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DocuSign Envelope ID:9B26E979-2C09-4BE7-801C-3DDB484D92EE XHIBIT A <br /> PROVIDER"S OUTSIDE AGENCY APPLICATION <br /> 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 /> Separate Spreadsheet provided <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? 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 /> Actual 2015-16 Estimated 2016-17 Projected 2017-18 <br /> Total Cost of Program $39,250 <br /> Total # of Individuals 50 <br /> Cost Per Individual $785 <br /> PROGRAM INFORMATION 2/8/2017 4:36:09 PM Page 16 • f 1 'T' <br />