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DocuSign Envelope ID: 535BB656- 53CF- 457A- 98B2- D73B9641501D 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 />KI 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 (CDBGIHOME /etc.) <br />• Private Foundation Grants <br />o 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 />3. This program budget represents what percent of the agency budget? 100% <br />4. COST PER INDIVIDUAL — Average $58.00 per participant/day <br />This Cost per Individual must reflect the total program budget divided by the total number of <br />program individuals in this application. (number of individuals served times 245 days/ year) <br />Page 22 of 26 <br />Total Cost of Program <br />$3747546 <br />$374,460 <br />393,460 <br />Total # of Individuals <br />21070 <br />22540 <br />23520 <br />Cost Per Individual <br />$56.00 <br />$60.00 <br />$59.00 <br />Page 22 of 26 <br />