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DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 <br />EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION <br />Program Budget <br />Operating Budget for Program <br />PROGRAM NAME Club Nova Community, Inc. - Oange County Funding -PSR Services -ACTT Members <br />Actual I Estimated ' I Projected Prrrcent <br />PROGRAM REVENUE mis-16 2016:17 2017 18 Ch'anaw <br />Private Donations <br />Program Generated Revenue <br />Local Government Grants: <br />Human Services - Town of Carrboro <br />Other - Town of Carrboro <br />Human Services - Town of Chapel Hill <br />Other - Town of Chapel Hill <br />Human Services - Orange County <br />Other - Orange County <br />Other - Town of Hillsborough <br />Other Government Grants <br />Triangle United Way <br />State Government <br />Federal Government (CDBGIHOMEIetc.) <br />Private Foundation Grants <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />- $ - $ - <br />$ - $ - <br />0 „ � <br />0 � <br />llf <br />a <br />Other Revenue : MCO County Allocations for ACTT j $ 68,000 1 $ 68,000 1 $ 68,000 1 $ - <br />Total Program Revenue I $ 83,000 I $ 83,000 I $ 83,000 ! 0% <br />PROGRAM EXPENSES <br />Compensation <br />Rent & Utilities <br />Supplies & Equipment <br />Travel & Training <br />Other Expenses: # of hours at PSR Reim. Rate <br />Total Program Expenses 1 <br />$ - <br />$ - <br />0 <br />- <br />$ - <br />$ - <br />0 <br />- <br />$ - <br />$ - <br />0 <br />- <br />$ - <br />$ - <br />0 <br />Other Revenue : MCO County Allocations for ACTT j $ 68,000 1 $ 68,000 1 $ 68,000 1 $ - <br />Total Program Revenue I $ 83,000 I $ 83,000 I $ 83,000 ! 0% <br />PROGRAM EXPENSES <br />Compensation <br />Rent & Utilities <br />Supplies & Equipment <br />Travel & Training <br />Other Expenses: # of hours at PSR Reim. Rate <br />Total Program Expenses 1 <br />$ - <br />$ - <br />$ - <br />0 <br />$ - <br />$ - <br />$ - <br />0 <br />$ - <br />$ - <br />$ - <br />0 <br />$ - <br />$ - <br />$ - <br />0 <br />$ 93,270 <br />$ 108,000 <br />$ 125,000 <br />16% <br />$ 93,270 <br />$ 108,000. <br />$ 125,000 <br />16% <br />SURPLUSI(DEFICIT) FOR PERIOD: $ (10,270) $ (25,000) $ (42,000) -68% <br />