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DocuSign Envelope ID: 1A43D806-0D44-4AC1-898C-3042FDBCA241 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> h) Agency Budget <br /> I. Is your agency currently receiving and/or requesting other (non-Human Services) <br /> local (Town of Carrboro, Town of Chapel Hill, Orange County) government <br /> funding? (Yes/No) No <br /> If yes, please list below: <br /> Include all programs that have funding requests/awards/totals from Carrboro, Chapel Hill, <br /> and Orange County governments (other than Human Services). DO NOT include federal <br /> funding sources, such as CDBG and HOME. <br /> Program FY16-17 FY17-18 Source <br /> Award Request <br /> Ex: Affordable Rental 0 $20,000 Carrboro -Affordable Housing <br /> Rehabilitation <br /> Ex: Agency Administration $15,000 $15,000 Carrboro— Other <br /> Ex. Total $15,000 $35,000 Carrboro Total Funding <br /> N/A <br /> *Add rows or attach additional page, if needed. <br /> Agency Information 1/27/2017 8:51:47 AM <br />