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DocuSign Envelope ID: 74839431 - 9216- 429F- BFA4- 2AC6473BD9D3 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />p) Program Budget <br />5. 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 (CDBGIHOMEfetc.) <br />• Private Foundation Grants <br />Other Revenue <br />Expenditures <br />a Compensation <br />o Rent & Utilities <br />o Supplies & Equipment <br />o Travel & Training <br />o Other Expenses <br />6. Program Budget Detail Provide description of "other" budget items, not defined. <br />7. This program budget represents what percent of the agency budget? 224% <br />8. COST PER INDIVIDUAL <br />This Cast per Individual must reflect the total program budget divided by the total number of <br />program individuals in this application. <br />PROGRAM INFORMATION 1/2312018 11:18:32 AM Page 27 of 30 <br />Actual 2016 -17 <br />Estimated 2017 -18 <br />Projected 2018 -19 <br />Total Cost of Program <br />$9022 <br />$9775 <br />$14000 <br />Total # of Individuals <br />4 <br />20 <br />30 <br />Cost Per Individual <br />$2225 <br />$489 <br />$466 <br />PROGRAM INFORMATION 1/2312018 11:18:32 AM Page 27 of 30 <br />