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DocuSign Envelope ID:4FF28E49-EE56-4A40-9331-F55AA8A05998 <br /> EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> f) 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 /> 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 /> N/A <br /> 3. This program budget represents what percent of the agency budget? 71% <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 123,800 141,500 173,000 <br /> Total # of Individuals 230 245 275 <br /> Cost Per Individual $538/year $577/year $629/year <br /> PROGRAM INFORMATION 1/23/2018 10:01:04 AM Page 21 of 24 <br />