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DocuSign Envelope ID:39EEFC69-D47C-4CE3-8A5C-0A87B55C2CD0 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 /> None noted. <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 program <br /> individuals in this application. Includes children AND family members <br /> Actual 2015-1.6 Estimated 2016-17 Projected 2017-18 <br /> Total Cost of Program $166,871 $162,375 $162,375 <br /> Total # of Individuals 143 225 250 <br /> Cost Per Individual $1,167,00 $721.00 $649.50 <br /> PROGRAM INFORMATION 2/9/2017 11:59:17 AM 0'' u q e 00 I "'" <br />