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DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <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 /> • Expenditures <br /> O Compensation <br /> O Rent& Utilities <br /> O Supplies & Equipment <br /> O Travel & Training <br /> O Other Expenses <br /> 10. Program Budget Detail — Provide description of "other" budget items, not defined. <br /> 11. This program budget represents what percent of the agency budget? % <br /> 12. 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 53,314 28,748 28,037 <br /> Total # of Individuals 8 circles 6 circles 6 circles <br /> Cost Per Individual $6664 $4791 $4673 <br /> PROGRAM INFORMATION 1/31/2017 11.43.55 AM Pago 33 of 35 <br />