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DocuSign Envelope ID: EE049453-18E5-41 DO-666D-662773AMC09 <br /> EXHIBITA: 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 /> • 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 /> • Other Government Grants <br /> • Triangle United Way <br /> • State Government <br /> • Federal Government (CDBG/HOME/etc.) <br /> • Private Foundation Grants <br /> • Other Revenue <br /> • Expenditures <br /> • Compensation <br /> • 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? 50% <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 2016-17 Estimated 2017-18 Projected 2018-19 <br /> Total Cost of Program $6,724 $18,288 $25,100 <br /> Total # of Individuals 12 24 27 <br /> Cost Per Individual $561 $731 $930 <br /> PROGRAM INFORMATION 1/23/2018 1:34:47 PM Page 23 of 2 <br />