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DocuSign Envelope ID: DDOCFB62- 8EDD- 4B57- ACF6- 9C98BO78AA95 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 As <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 />• Private Donations <br />• Program Generated Revenue <br />• 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 />• Other Government Grants <br />• Triangle United Way <br />• State Government <br />• Federal Government (CDBG /HOME /etc.) <br />• Private Foundation Grants <br />• Other Revenue <br />Expenditures <br />• Compensation <br />• Rent & Utilities <br />• Supplies & Equipment <br />• Travel & Training <br />• Other Expenses <br />2. Program Budget Detail — Provide description of "other" budget items, not defined. <br />Other items include communications - internet access, cloud storage, telephones and <br />copier /scanner. <br />3. This program budget represents what percent of the agency budget? 57% <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 />j <br />Actual 2015- <br />16 <br />Estimated 2016- <br />17 <br />Projected 2017- <br />18 <br />Total Cost of Program <br />$238,714 <br />$290,883 <br />$252,671 <br />Total # of Individuals <br />533 <br />653 <br />568 <br />Cost Per Individual <br />$447 <br />$445 <br />$445 <br />PROGRAM INFORMATION 1/31/2017 10:54:56 AM P a g e 1 6 o f 2 6 <br />