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DocuSign Envelope ID:C4C09F35-022B-45DE-8313-4A1ED7AF458B XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> n) Program Budget (See Attached) <br /> 1. Submit your program budget. You may complete the provided template (separate xls <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 /> o Private Donations <br /> o Program Generated Revenue <br /> o 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 /> o Other Government Grants <br /> ■ Triangle United Way <br /> ■ State Government <br /> ■ Federal Government (CDBG/HOME/etc.) <br /> ■ Private Foundation Grants <br /> o Other Revenue <br /> • Expenditures <br /> o Compensation <br /> o Rent & Utilities <br /> o Supplies & Equipment <br /> o Travel & Training <br /> o Other Expenses <br /> 2. Program Budget Detail — Provide description of"other" budget items, not defined. <br /> The other expenses include: depreciation ($12,052), bank fees ($15,392), extra <br /> performer fees ($1,881), transportation ($23,900), and rent ($410). <br /> 3. This program budget represents what percent of the agency budget? 39.5% <br /> 4. COST PER INDIVIDUAL (For Youth Programs Only) <br /> This Cost per Individual must reflect the total program budget divided by the total number of <br /> program individuals in this application. <br /> Actual 2015-16 Estimated 2016-17 Projected 2017-18 <br /> Total Cost of Program 587,225 572,173 593,378 <br /> Total # of Individuals 29,777 30,000 31,000 <br /> Cost Per Individual $19.72 $19.72 $19.14 <br /> PROGRAM INFORMATION 2/8/2017 5:24:23 PM Page 18 of 20 <br />