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DocuSign Envelope ID: A899BE5E- BAEC- 40F3 -91 E1- A9D77FC4C488 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />p) Program Budget <br />1. Submit your program budget. Submit your program budget. <br />See attached <br />2. Program Budget Detail - Provide description of "other" budget items, not defined. <br />Other Line items include contracted services, communications, printing and copying, <br />community training, dues and subscriptions, participant incentives <br />3. This program budget represents what percent of the agency budget? 30% <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 1/22/2018 10:14:21 AM Page 16 of 33 <br />Actual 2016 A7 : <br />Estim,ated 2017-1 8 <br />Pro'ected 201$ -19 <br />_.l <br />Total Cost of Program <br />$240,271 <br />$398,477 <br />$408572 <br />Total # of Individuals <br />(totals for all three initiatives <br />resented in grant application) <br />1739 +383-144- <br />2200 <br />1350 +500 +85 = <br />1935 min <br />1500 +500 +100= <br />2900 min <br />Cost Per Individual <br />1 $106 <br />$205 <br />$195 <br />PROGRAM INFORMATION 1/22/2018 10:14:21 AM Page 16 of 33 <br />