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DocuSign Envelope ID:88AEE9BF-924A-442D-BD41-DC640F1 E1 BAC <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> g) 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) Human Services funding and JCPC matching funds <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 /> Restorative Practices and 9,000 $10,000 Carrboro <br /> Mediation for Youth <br /> Restorative Practices and $14,000 $15,000 Chapel Hill <br /> Mediation for Youth <br /> Mediation — Court and Family $80,000 $83,000 Orange County <br /> Total 103,000 108,000 <br /> Restorative Practices and 8118 9000 Orange County JCPC matching <br /> Mediation for Youth funds <br /> *Add rows or attach additional page, if needed. <br /> ii. Submit your agency's budget. You may complete the provided template (separate <br /> xls file) or you may submit your own budget file (as long as it contains the same <br /> information, and in a similar format, as requested in the provided template). <br /> Agency Budgets are required to define budget amounts for the previous program <br /> year, current program year, and next program year for the following categories: <br /> • Revenues <br /> o Private Donations <br /> o Program Generated Revenue <br /> o Local Government Grants <br /> • Carrboro Human Services <br /> • Carrboro Other <br /> Agency Information 2/8/2017 11:26:12 AM Page in J 22 <br />