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DocuSign Envelope ID: FOFFD659- 4159- 4D4C- 82FD- FF8E51A5A7E4 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />10. Program Budget <br />11. 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 Mere) <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 (CDBGIHOMEfetc.) <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 />12. Program Budget Detail — Provide description of "other" budget items, not defined <br />Other revenue includes fundralsers, special events and endowment income. Other <br />expenses include items such as contract services, fundraising expenses and <br />telephonefinternet costs. <br />13. This program budget represents what percent of the agency budget? 17.8% <br />14. 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 1/22/2018 5.50:18 PM Page 3 3 of 47 <br />Total Cost of Program <br />$107,444.00 <br />$119,957.00 <br />$166,807.00 <br />Total # of Individuals <br />925 <br />570 <br />670 <br />Cost Per Individual <br />$116.16 <br />$210.45 <br />$248.97 <br />PROGRAM INFORMATION 1/22/2018 5.50:18 PM Page 3 3 of 47 <br />