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DocuSign Envelope ID:ODO4B5DD-363F-41 FF-BD24-FAD291133B51 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <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) No <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 /> *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 /> DO NOT SUBMIT THIS PAGE 12/15/2016 9:57:17 AMIII' : 16 •r 32 <br />