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DocuSign Envelope ID: B67A2C26-3304-4095-BB1C-73A2BC4A569A <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> #of Volunteers: 2,049 # of FTE - Volunteers: 10 <br /> g) Living Wage <br /> Does this agency pay permanent employees a minimum living wage? (Yes/No) Yes <br /> If yes, is this agency an Orange County Living a rtifi Employer? Yes <br /> If no, please explain. <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 funding? <br /> (Yes/No)Yes <br /> If yes, please list below: <br /> Include all programs that have funding requests/awards/totals from Carrboro, Chapel Hill, and <br /> Orange County governments (other than Human Services). DO NOT include federal funding <br /> sources, such as CDBG and HOME. <br /> Program FY16-17 FY17-18 Source <br /> Award Request <br /> Northside Homebuyer Support $105,000 $0 Chapel Hill Affordable Housing <br /> - Second Mortgage Assistance Reserve Fund <br /> Impact Fee Reimbursements $96,476 $103,000 Orange County <br /> Land Purchase - Northside $55,000 $0 Chapel Hill Affordable Housing <br /> Reserve Fund <br /> Senior Housing at Waterstone $0 $500,000 Orange County/Hillsborough <br /> Infrastructure Costs <br /> *Add rows or attach additional page, if needed. <br /> ii. Submit your agency's budget. You may complete the provided template (separate <br /> xis 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 /> • Chapel Hill Human Services <br /> • Chapel Hill Other (DO NOT include CDBG funding here) <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 /> DO NOT SUBMIT THIS PAGE 1/31/2017 2:31 :06 PM Page of °'f <br />