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DocuSign Envelope ID:B32F3E9F-996A-4000-8CAF-83514F2E5759 t A- continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> AGENCY NAME: <br /> Actual Estimated Projected Percent <br /> AGENCY REVENUE 2014.15 2015.16 2016.17 Chan e <br /> Private Donations MN= 5 496,285 <br /> Agency Generated Revenue(fees) 111111111111111111111111 0 <br /> Local Government Grants: <br /> Orange County $ $ tl $ 10,000 0 <br /> Town of Chapel Hitll $ $ 2,000 $ 10,000 400% <br /> Town of Carrboro • III . 10,000 400% <br /> Other Local 0 <br /> Other Local 1111.111111101.11111111111111111111111.111 <br /> Other Locatl: 1111111.111111111111111111111.11111111111111111111111 •1 <br /> If were than 3 sources,please <br /> provide a separate hst <br /> Non-Local Government Grants <br /> Triangtle United Way 11111111111.11111111111111111101111111111 01 <br /> State Government 11111111111111111111111111111111111111110111111111M <br /> Federal <br /> rill I. 1110.11.11 0 <br /> Other Grants 11.11111111111.11.011111111.11111110. 0 <br /> Other Grants. 111.11111111111111111.111111111111111111. 0 <br /> Miscellaneous/Other Revenue 0 <br /> Please list 3 largest Mecellaneus sources <br /> $ <br /> - <br /> Total Agency Revenue PIENVIEFINggiallin <br /> AGENCY EXPENSES <br /> Compensation S $ 101,399 $ 119,056 .11E1 <br /> Rent&Utilities <br /> $ 46,100 <br /> Supplies&Equipment $ 296,029 1=111= <br /> Travel&Training $ 1,45• $ 1,600 10% <br /> Other Expenses: 24,500 <br /> Please list 3 largest"Other Fxpenses" <br /> COntrad Services $ 9,780 00 <br /> Payroll $ 7,765 00 <br /> Insurance $ 3,37'8 00 <br /> Total Agency Expenses $ 307 098 <br /> SURPLUS/(DEFICIT)FOR PERVOD: $ 34,015 $ _21 <br /> Main Application 1/25/2016 11:34:49 AM Paqu 21 of <br />