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DocuSign Envelope ID: EB541A3B-1E01-49AB-9E09-7987ECAEC1C4 t A - continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> Program Budget <br /> Agency/Prograrr Back to School Bash <br /> ri-V041V: <br /> AGENCY REVENUE 0,2014415 201647 <br /> Private Donations $ 3,000 $ 5,000 $ 7,000 40% <br /> Agency Generated Revenue(fees) 0 <br /> Local Government Grants <br /> Orange County $ 10,000 $ 15,000 $ 8,000 -47% <br /> Town of Chapel Hill $ 2,000 $ 2,500 $ 3,000 20% <br /> Town of Carrboro $ 2,500 $ 3,000 $ 3,500 17% <br /> Other Local: 0 <br /> Other Local: 0 <br /> Other Local: 0 <br /> If more than 3 sources,please <br /> provide a separate 1st. <br /> Non-Local Government Grants <br /> Triangle United Way 0 <br /> State Govemment 0 <br /> Federal Gmemment 0 <br /> Other Grants:2 Smith Reynolds - $ 10,000 $ 10,000 0% <br /> Other Grants: 0 <br /> Miscellaneous/Other Revenue 0 <br /> Please list 3 largest Iviscellanous sources: <br /> - <br /> $ - <br /> Total Agency Revenue $ 17 500 $ 35 500 $ 31 500 -11% <br /> AGENCY EXPENSES <br /> Compensation 0 <br /> Rent&Utilities 0 <br /> Supplies&Equipment 0 <br /> Travel&Training 0 <br /> Other Expenses: 0 <br /> Please list 3 largest"Other Expenses": <br /> - <br /> Total Agency Expenses - $ - $ 0 <br /> SURPLUS/(DEFICIT)FOR PERIOD: 1$ 17,500 I$ 35,5001$ 31,500 I -11% <br /> Main Application 2/2/2016 5:08:53 PM Page 23 of 32 <br />