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DocuSign Envelope ID: E30588DE -A1 BC- 443D- A5C4- 3BE790331500 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />ff) 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 />Please see attached BI1S Budget Worksheet 2018 -2019 Adapted Competition <br />Events Budget. <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 />o 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 (CDBGIHOMEIetc.) <br />• Private Foundation Grants <br />• Other Revenue <br />Expenditures <br />o Compensation <br />o Rent & Utilities <br />o Supplies & Equipment <br />• Travel & Training <br />• Other Expenses <br />6. Program Budget Detail — Provide description of "other" budget items, not defined. <br />Staff and Coach Development, Insurance <br />7. This program budget represents what percent of the agency budget? 21.7% <br />8. COST PER INDIVIDUAL <br />This Cost per Individual must reflect the total program budget divided by the total number of <br />program individuals in this application. <br />L��W <br />z �►cfia216 °'(7 <br />�'r ' <br />Eet�m01�7 18.sPro�ecte <br />,. <br />0j1 �, <br />8,��✓19�y <br />Total Cost of Program <br />$208,620 <br />$219,050 <br />$230,000 <br />Total # of Individuals <br />632 <br />625 <br />675 <br />Cost Per Individual <br />$330.09 <br />$350.48 <br />$340.74 <br />PROGRAM INFORMATION 1/22/2018 10:12:15 AM Page 27 of 30 <br />