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DocuSign Envelope ID: 6818677A -D518- 4750- B391- F6169FB2A4C4 <br />Exhibit A: Provider's Outside Agency Application <br />o) Program Budget <br />1. Submit your program budget. (use template) <br />2. Program Budget Detail — Provide description of "other" budget items, not defined. <br />a. Insurance: Workers Comp, General liability, Board Liability <br />b. Background Checks <br />c. Intern Mileage :.14 per mile <br />d. Advertising for interns and volunteers <br />e. Marketing /Printing <br />f. Technology <br />g. Volunteer /Intern Recognition: end of semester client celebration, annual <br />volunteer/intern recognition event <br />3. This program budget represents what percent of the agency budget? 3% <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 />PROGRAM INFORMATION 1/23/2018 11:40:33 AM Page 1 9 of 21 <br />Actual 2016 -17 <br />Estimated 2017 -18 Projected 2018-19 <br />Total Cost of <br />Program /Outside <br />14,000 <br />15,000 16,000 <br />Agency <br />Total # of lndividuals <br />293 <br />295 325 <br />Cost Per Individual <br />47.78 <br />50.8 49.23 <br />PROGRAM INFORMATION 1/23/2018 11:40:33 AM Page 1 9 of 21 <br />