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DocuSign Envelope ID: E7784BE7- 82AF- 4AF1- AA11- 944D2300E76D <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />1. Submit your program budget. You may complete the provided template (separate xls <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 />• 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 />None noted. <br />3. This program budget represents what percent of the agency budget? 8% <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 3:23:54 PM <br />Actual 2016 -17 <br />Estimated 2017 -18 <br />Projected 2018 -19 <br />Total Cost of Program <br />$171,186 <br />$145,578 <br />$145.578 <br />Total # of Individuals <br />185 <br />225 <br />275 <br />Cost Per Individual <br />$925.33 <br />$647.00 <br />$529.37 <br />PROGRAM INFORMATION 1/22/2018 3:23:54 PM <br />