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DocuSign Envelope ID: 3F05AA6E -4F62- 4678- 8F07- 34D6E1679E9A <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 budget includedsheet alongside the agency budget. <br />2. Program Budget Derr PrAvide description of "other" budget items, not defined. <br />The Donation Station p1wram will seek partnerships with local businesses in the <br />form of sponsorship to offset costs and further promote community <br />engagement. # <br />3. This program budget represents what perc a agency budget? 6_5% <br />4. COST PER INDIVIDUAL <br />This Cost per Individual must reflect the total prog budget 'vided by the total number of <br />program individuals in this application. <br />PROGRAM INFORMATION 2/16/2018 1 :09:05 PM Page 19 of 20 <br />Actual 2016 -17 <br />Estimated 2017 -18 <br />Projected 2018 -19 <br />Total Cost of Program <br />76,000 <br />84,874 <br />93,000 <br />Total # of Individuals <br />8,300 <br />9,000 <br />7,887 <br />Cost Per Individual <br />$9.16 <br />$9.42 <br />$11.79 <br />PROGRAM INFORMATION 2/16/2018 1 :09:05 PM Page 19 of 20 <br />