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DocuSign Envelope ID: E8DFACF7 -45BE- 435E- 9B5A- BB177E968F07 <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 As <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 />c Private Donations <br />© 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 (CDBGIHOME /etc.) <br />• Private Foundation Grants <br />o Other Revenue <br />• Expenditures <br />o Compensation <br />c Rent & Utilities <br />o Supplies & Equipment <br />c Travel & Training <br />o Other Expenses <br />2, Program Budget Detail Provide description of "other" budget items, not defined. <br />Administrative Expenses $2,544,474 <br />Nursing Home Room & Board $ 410,000 <br />Employee Travel for Visiting Staff $ 202,198 <br />3. This program budget represents what percent of the agency budget? 100% <br />4. COST PER INDIVIDUAL <br />This Cost per Individual must reflect the total program budget divided by the total number of program <br />individuals in this application. <br />DO NOT SUBMIT THIS PAGE 1/19/2018 3:37:52 PM P . -q - 1 1 0 f i 1 <br />Actual 2016 -17 <br />Estimated 2017 -18 <br />Projected 2018 -19 <br />Total Cost of Program <br />$12,572,290 <br />$13,181,198 <br />$13,780,000 <br />Total # of Individuals <br />$58,775 <br />$60,538 <br />$61,749 <br />Cost Per Individual <br />$213.91 <br />$221.65 <br />$223.16 <br />DO NOT SUBMIT THIS PAGE 1/19/2018 3:37:52 PM P . -q - 1 1 0 f i 1 <br />