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DocuSign Envelope ID:E522BFFC-A634-4A11-A162-195A3BE957A4 <br /> EXHIBIT 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 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 /> (3) Largest Expenses: <br /> Administrative Allocation $2,323,790.08** <br /> Professional Services $1,085,997 <br /> Nursing Home Room & Board $ 416,675 <br /> **Hospice portion of administrative departments, referral center, development, finance, <br /> marketing, facilities management. <br /> 3. This program budget represents what percent of the agency budget? 7% <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 Estimated 2016-17 Projected 2017-18 <br /> Total Cost of Program J $18,911 $19,000 $19,000 <br /> Total # of Individuals J 42 45 50 <br /> Cost Per Individual j 450 422 380 <br /> PROGRAM INFORMATION 1/26/2017 9:44:41 AM Page 15 of 18 <br />