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DocuSign Envelope ID:E519448F-9F6D-4100-BF62-D7625621FFEB XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 0 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 /> 0 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 /> Ia 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 /> 3. This program budget represents what percent of the agency budget? 5% <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 I Estimated 2016-17 Projected 2017-18 <br /> Total Cost of Program $160,375 $154,784 $165,567 <br /> Total # of Individuals 1,564 995 1,052 <br /> Cost Per Individual $103 $156 $157 <br /> PROGRAM INFORMATION 1/31/2017 3:59:06 PM Page 17 of 18 <br />