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DocuSign Envelope ID: 4B292955- 9A36- 47C6- BDDE- 4E9CDOBA074D <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 xis <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 />c Private Donations <br />c 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 />o Compensation <br />o Rent & Utilities <br />o Supplies & Equipment <br />o Travel & Training <br />o Other Expenses <br />2. Program Budget Detail — Provide description of "other" budget items, not defined. <br />Audit - $4,800 <br />Fundraising - $6,099 <br />Workers compensation insurance - $4,223 <br />Liability insurance - $3,550 <br />Youth activities - $1,543 <br />Girls group coordinator - $2,500 <br />Telephone - $2,858 <br />IT and graphic design support - $365 <br />Internet - $1,306 <br />Repairs & maintenance - $982 <br />Restitution payments - $2,461 <br />Volunteer training and support - $176 <br />Professional development - $256 <br />Miscellaneous - $96 <br />3. This program budget represents what percent of the agency budget? 104% <br />4. COST PER INDIVIDUAL <br />PROGRAM INFORMATION 1/19/2018 3:14:36 PM Page 21 of 25 <br />