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DocuSign Envelope ID: FCA96EA6-6080-4E8E-8EFF-B03ECA597827 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> e) 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 /> • Local Government Grants <br /> • Carrboro Human Services <br /> • Carrboro Other <br /> I 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 /> I Triangle United Way <br /> • State Government <br /> I Federal Government(CDBG/HOME/etc.) <br /> • Private Foundation Grants <br /> • Other Revenue <br /> * Expenditures <br /> • Compensation <br /> O Rent& Utilities <br /> • Supplies & Equipment <br /> O Travel &Training <br /> • Other Expenses <br /> 2. Program Budget Detail—Provide description of"other" budget items, not defined. <br /> Other budget items include event revenues and expenses, fees and grants associated <br /> with our affiliation with Boys & Girls Clubs of America, and professional fees (audit and <br /> consulting). <br /> 3. This program budget represents what percent of the agency budget? 25% <br /> 4. COST PER INDIVIDUAL <br /> This Cost per Individual must reflect the total program budget divided by the total number of program <br /> individuals in this application. <br /> Actual nil Actual 201if Projected 2017-18 <br /> Total Cost of Program $529,520 I $570,695 $661,700 <br /> Total#of Individuals I 453 490 <br /> Cost Per Individual $1,260 $1,350 <br /> DO NOT SUBMIT THIS PAGE 1/26/2017153256 al/pi F" n g a 20 1 22 <br />