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DocuSign Envelope ID: A899BE5E- BAEC- 40F3 -91 E1- A9D77FC4C488 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />s} Program Budget <br />9. Submit your program budget. <br />See attached <br />10. 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 />11. This program budget represents what percent of the agency budget? 30% <br />12. 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 P a cj e 3 2 o f :33 <br />Actua! 2016. =17 <br />Estimated 2017 18 <br />Projected 2018 -19 <br />Total Cost of Program <br />$240,271 <br />$398,477 <br />$408572 <br />Total # of Individuals <br />(totals for all three initiatives <br />presented in grant application) <br />1739+383 +144= <br />2266 <br />1350 +500 +85 = <br />1935 min <br />1500 +500 +100= <br />2100 min <br />Cost Per Individual <br />$106 <br />$205 <br />$195 <br />PROGRAM INFORMATION 1/22/2018 10:14:21 AM P a cj e 3 2 o f :33 <br />