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DocuSign Envelope ID: 5D25D6E0-716B-4244-AEA3-02E6A45FD852 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <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 /> iii. Does your agency budget show a Surplus or Deficit? No <br /> Is there a significant change?Yes/No No <br /> Please provide a brief explanation for Surplus or Deficit, and significant changes. <br /> iv. What is your agency's fiscal year? January 1, 2017—December 1, 2017 <br /> (Example: July 1, 2016 through June 30, 2017) <br /> Agency Information 1/31/2017 11:04:24 AM Page 12 ar 2 <br />