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DocuSign Envelope ID: 10F0B4DA-C8B5-4AB3-9AFA-939AE0010B18 (HIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> n) 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 ;,mounts for the previous rogram <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 /> a 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 /> "Other expenses" includes insurance, printing, online services, and postage & <br /> miscellaneous. <br /> 3. This program budget represents what percent of the agency budget? 17% <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 E;timated 2016.17 Pro acted 2017-10 <br /> Total Cost of Program $50,312 $58,955 $69,500 <br /> Total # of Individuals 1443 1690 2048 <br /> Cost Per Individual i $34.87 $34.88 $33.94 <br /> PROGRAM INFORMATION 1/31/2017 10:50:57 AM <br />