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DocuSign Envelope ID: D068E7B0- D869- 43F4- B35C- 428F10E3BDC1 <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 />• 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 (CDBG /HOME /etc.) <br />• Private Foundation Grants <br />• Other Revenue <br />Expenditures <br />• Compensation <br />• Rent & Utilities <br />• Supplies & Equipment <br />• Travel & Training <br />• Other Expenses <br />2. Program Budget Detail — Provide description of "other" budget items, not defined. <br />These would include insurance, printing, and the costs of our audit, as allocated <br />to this budget. <br />3. This program budget represents what percent of the agency budget? 32% <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 1/22/2018 4:11:17 PM <br />Actual 2016 -17 <br />Estimated 2017 -18 <br />Projected 2018 -19 <br />Total Cost of Program <br />152,075 <br />153,190 <br />158,000 <br />Total # of Individuals <br />606 <br />640 <br />650 <br />Cost Per Individual <br />250 <br />239 <br />243 <br />PROGRAM INFORMATION 1/22/2018 4:11:17 PM <br />