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DocuSign Envelope ID: B67A2C26-3304-4095-BB1C-73A2BC4A569A <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <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? Our budget for FY17 shows a <br /> surplus of $15,659. <br /> Is there a significant change? Yes/No No. <br /> Please provide a brief explanation for Surplus or Deficit, and significant changes. <br /> The surplus is due to revenue being budgeted slightly higher than expenditures this year. <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 /> 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) <br /> Program Name: Home Preservation <br /> Program Primary Contact and Title: Adwoa Asare, Associate Director of Community Development <br /> and Engagement <br /> Telephone Number: (919) 932-7077 ext. 233 E-Mail: aasare @orangehabitat.org <br /> a) Indicate the type of Human Service Needs Priority, if program applicable: <br /> ® Priority Area #1: safety-net services for disadvantaged residents <br /> ❑ Priority Area #2: education, mentorship, and afterschool programming for <br /> youth facing a variety of challenges <br /> ❑ Priority Area#3: programs aimed at improving health and nutrition of needy residents <br /> b) Indicate the type of program for which you are requesting funding <br /> (Check all that apply to this program) <br /> Program Category Youth Adult Elderly Disabled Public Housing <br /> Neighborhoods/Residents <br /> Affordable Housing X X X <br /> Affordable Healthcare <br /> Education <br /> Family Resources <br /> Jobs/Jobs Training <br /> Food <br /> Transportation <br /> Other: Please specify <br /> DO NOT SUBMIT THIS PAGE 1/31/2017 2:31 :06 PM page it f 'f <br />