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DocuSign Envelope ID: 2AC82140-8F6C-4125-8743-OB8594E61466
<br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
<br />Rent and Utilities
<br />(Rent, Utilities, Building Maintenance, Moving)
<br />45,200
<br />40,035
<br />49,252
<br />Other Employee - Related Expenses
<br />(Training, Reviews, Workers' Comp, Travel)
<br />526
<br />1,652
<br />1,701
<br />Other Expenses
<br />Contract and Professional Svcs
<br />(CPA, Accounting, Marketing)
<br />0
<br />0
<br />0
<br />Development and Fundraising
<br />0
<br />0
<br />0
<br />Office Expenses
<br />(Fees, Office Supplies, Postage, Printing,
<br />Etc.)
<br />4,754
<br />4,906
<br />5,053
<br />Information Technology
<br />2,700
<br />4,236
<br />6,389
<br />Vehicle Expenses
<br />(Registration, Maintenance, Insurance,
<br />Fuel)
<br />1,470
<br />1,570
<br />1,617
<br />Operations
<br />(Liability Insurance, Depreciation,
<br />Meetings, Inventory Adjustment, Etc.)
<br />2,141
<br />2,077
<br />2,139
<br />Total Other Expenses
<br />11,064
<br />12,789
<br />15,197
<br />Total Expense
<br />409,482
<br />477,278
<br />574,936
<br />Net Ordinary Income
<br />111,868
<br />135,905
<br />135,024
<br />Net Income
<br />111,868
<br />135,905
<br />135,024
<br />
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