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DocuSign Envelope ID:F9ADA870-944A-40DD-98D0-3DB55F3AD8E5 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <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/HOMEIetc.) <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? July 1, 2016 through June 30, 2017 <br /> (Example: July 1, 2016 through June 30, 2017) <br /> Agency Information 1/27/2017 10:08:56 AM Page 1 1 of 2 2 <br />