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DocuSign Envelope ID: 1640431D- 872F- 4BC9- ACA1- 2226D9788920 <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 (CDBGIHOMEIetc.) <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 expenses include Contracted Services, Repair and Maintenance, Stipends, Meeting <br />Expenses, and Dues and Subscriptions needed for the program. <br />3. This program budget represents what percent of the agency budget? 7% <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 6:18:22 PM Page 1 9 of 22 <br />Actual 2016 -17 <br />Estimated 2017 -18 <br />Projected 2018 -19 <br />Total Cost of Program <br />$204,474 <br />$236,997 <br />$240,396 <br />Total # of Individuals <br />1,040 <br />1,197 <br />1,197 <br />Cost Per Individual <br />$197 <br />$198 <br />$201 <br />PROGRAM INFORMATION 1/22/2018 6:18:22 PM Page 1 9 of 22 <br />