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DocuSign Envelope ID: C5C1 1 FD4-56CD-48FD-BBD1 -95F2AFF7112B <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 xfs <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 />Q 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 />* Other Government Grants <br />• Triangle United Way <br />• State Govemment <br />• Federal Government (CDBGIHOMEIetc.) <br />• Private Foundation Grants <br />a 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 />3. This program budget represents what percent of the agency budget? 10 % <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 />Total Cost of Program <br />Total # of Individuals <br />Cost Per Individual <br />PROGRAM INFORMATION <br />Actual 20161 -17 Estimated 2017 -18 Projected 2018 -19 <br />nla <br />1 {23/2018 12:09:02 PM Page 24 of 27 <br />