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DocuSign Envelope ID: FOFFD659- 4159- 4D4C- 82FD- FF8E51A5A7E4 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />16. Program Budget <br />17. Submit your program budget. You may complete the provided template (separate xis <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 />• 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 (CDBGfHOMEletc.) <br />• Private Foundation Grants <br />• Other Revenue <br />Expenditures <br />o Compensation <br />o Rent & Utilities <br />• Supplies & Equipment <br />• Travel & Training <br />• Other Expenses <br />18. 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 />telephonefinternet costs. <br />19. This program budget represents what percent of the agency budget? 25.5% <br />20. 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 112212018 5:50:18 PM Page 44 of 47 <br />Total Cost of Program <br />$213,620.00 <br />$218,254.00 <br />$239,417.00 <br />Total ## of Individuals <br />4441 <br />4500 <br />4500 <br />Cost Per Individual <br />$48.10 <br />$48.50 <br />$53.20 <br />PROGRAM INFORMATION 112212018 5:50:18 PM Page 44 of 47 <br />