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DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> n) Program Budget <br /> 1. Submit your program budget. You may complete the provided template (separate xls file) <br /> or you may submit your own budget file (as long as it contains the same information, in the <br /> 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 /> a. Survey incentives of a $5 gas card will be given to the first 200 parents that <br /> answer our parent evaluation at the end of the session. We are hoping to <br /> receive more parent feedback by offering these incentives. $5 x 200 <br /> parents=$1,000 <br /> b. Transportation for parents to get their child to camp. cost is $30/day for 5-day <br /> camp=$150 per child. Given to 10 children = $1,500. <br /> 3. This program budget represents what percent of the agency budget? 44.4 % <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 2017-18 <br /> Total Cost of Program 223,702 276,334 291,258 <br /> Total # of Individuals 1,555 1,609 1,641 <br /> Cost Per Individual 144 172 177 <br /> 1/12/2017 2:56:42 PM Page 27 •f 29 <br />