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DocuSign Envelope ID:380F50AD-C98D-426B-80DC-9Al34EB8DA24 XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> n) Program Budget <br /> 1. Submit your program budget. You may complete the provided template <br /> (separate As file) or you may submit your own budget file (as long as it contains <br /> the same information, in the same format, as requested in the provided <br /> template). <br /> Program Budgets are required to define budget amounts for the previous <br /> program year, current program year, and next program year for the <br /> 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 <br /> 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 <br /> defined. <br /> The largest part of the "Other Expenses" line item is graphic design and <br /> development cost. There is also the cost associated with training the <br /> 3. This program budget represents what percent of the agency budget? 25% <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 /> Actual 2015-16 Estimated 2016-17 Projected 2017-18 <br /> Total Cost of Program 52500 47500 <br /> Total # of Individuals 60325 60325 <br /> Cost Per Individual $0.87 $0.79 <br /> PROGRAM INFORMATION 1/31/2017 3:02:18 PM Page 16 of 18 <br />