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DocuSign Envelope ID: FOFFD659- 4159- 4D4C- 82FD- FF8E51A5A7E4 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />p) 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 />Other revenue includes fundraisers, special events and endowment income. Other <br />expenses include items such as contract services, fundraising expenses and <br />telephone /internet costs. <br />3. This program budget represents what percent of the agency budget? 39.2% <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 />R <br />Total Cost of Program <br />$326,530.00 <br />$363,400.00 <br />$367,121.00 <br />Total # of Individuals <br />1217 <br />1220 <br />1220 <br />Cost Per Individual <br />$268.31 <br />$297.86 <br />$300.92 <br />PROGRAM INFORMATION 112212018 5:50:18 PM Page 23 of 47 <br />