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DocuSign Envelope ID: 717C8AE2- 4D6E- 4E46- A9A7- F4213973D039 <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 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 />• Focal 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 (CDBGfHOMEfetc.) <br />• Private Foundation Grants <br />• Other Revenue <br />Expenditures <br />o Compensation <br />o Rent & Utilities <br />• Supplies & Equipment <br />• Travel & Training <br />• Other Expenses <br />2. Program Budget Detail — Provide description of "other" budget items, not defined. <br />3. This program budget represents what percent of the agency budget? 100% <br />4. 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 />PROGRAM INFORMATION 1/23/2018 1:58:29 PM Page 28 of 31 <br />Actual 2016 -17 <br />Estimated 2017 -18 <br />Projected 2018 -19 <br />Total Cost of Program <br />$865,240 <br />$899,082 <br />$908,000 <br />Total # of Individuals <br />112 <br />125 <br />141 <br />Cost Per Individual <br />$7,725 <br />$7,192 <br />$6,439 <br />PROGRAM INFORMATION 1/23/2018 1:58:29 PM Page 28 of 31 <br />