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DocuSign Envelope ID: 7A9252AF- OE3A- 47EE- A4F6- 2A3D9DF527FF <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 />• 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 />"Other" here includes primarily direct costs for home repairs, specifically our emergency <br />home repair program. Additionally, a small percentage includes insurance, printing, <br />postage, and miscellaneous. <br />3. This program budget represents what percent of the agency budget? 28% <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 1/23/2018 2:58:40 PM Page 9 of 10 <br />Actual 2016 -17 <br />Estimated 2017 -18 <br />Projected 2018 -19 <br />Total Cost of Program <br />$73,959 <br />$90,539 <br />$127,000 <br />Total # of Individuals <br />75 <br />94 <br />136 <br />Cost Per Individual <br />$986.12 <br />$963.18 <br />$933.82 <br />PROGRAM INFORMATION 1/23/2018 2:58:40 PM Page 9 of 10 <br />