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DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 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 /> 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 /> 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 /> 2. Program Budget Detail — Provide description of"other" budget items, not defined. <br /> Survey incentives of a $5 gas card will be given to the first 50 parents that answer <br /> our parent evaluation at the end of the session. We are hoping to receive more <br /> parent feedback by offering these incentives. <br /> 3. This program budget represents what percent of the agency budget? 1.75% <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 2015-16 Estimated 2016-17 Projected 2 017-18 <br /> Total Cost of Program 39,489 9,224 11,510 <br /> Total # of Individuals 740 70 283 <br /> Cost Per Individual 53.36 131.77 40.67 <br /> 1/12/2017 2:56:42 PM Page 19 •f 29 <br />