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DocuSign Envelope ID: C5305795- 2DF5- 4A04- B090- 9F458AA520CB <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 />o Private Donations <br />o 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 (CDBGIHOMEIetc.) <br />• Private Foundation Grants <br />o 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? 40 % <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 2:17:04 PM Page 1 4 o f 15 <br />Actual 2016 -17 <br />Estimated 2017 -18 <br />Projected 2018 -19 <br />Total Cost of Program <br />$565,000 <br />$591,100 <br />$629,600 <br />Total # of Individuals <br />109 <br />118 <br />120 <br />Cost Per Individual <br />$5188 <br />$5009 <br />$5242 <br />Total # of Service Days <br />7010 <br />7700 <br />8200 <br />Cost Per Individual <br />$81 <br />$77 <br />$77 <br />PROGRAM INFORMATION 1/22/2018 2:17:04 PM Page 1 4 o f 15 <br />