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DocuSign Envelope ID: DB2FC63F- 0403 - 4403- BF86- OF5CB206F3F3 <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 (CDBGIHOMEletc.) <br />• Private Foundation Grants <br />• Other Revenue <br />• Expenditures <br />o Compensation <br />o Rent & Utilities <br />a Supplies & Equipment <br />o Travel & Training <br />n 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? 100 % <br />4. COST PER INDIVIDUAL <br />This Cost per Individual must reflect the total program budget divided by the total number of program <br />individuals in this application. <br />y F :n r7.-ry '7 <br />,Sh,i NO �N <br />Total Cost of Program <br />$18,620 <br />$63,158* <br />$94,950 <br />Total # of Individuals <br />65 (avg) <br />120 <br />120 <br />Cost Per Individual <br />1 $285 <br />$526* <br />$790 ($395/meal) <br />("increase due to <br />hiring Exec Director) <br />DO NOT SUBMIT THIS PAGE 1/12/2018 10,05:28 AM Page 22 of 25 <br />