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DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 <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 <br /> funding? (Yes/No) No <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 /> Ex: Affordable Rental 0 $20,000 Carrboro -Affordable Housing <br /> Rehabilitation <br /> Ex: Agency Administration $15,000 $15,000 Carrboro—Other <br /> Ex. Total $15,000 $35,000 Carrboro Total Funding <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 /> Please refer to the attachment titled "BITS Agency and Program Budgets" to view <br /> the agency budget. In this document, we have provided our full agency budget, as <br /> well as the revenue portion of the budget worksheet template provided within the <br /> grant application. <br /> iii. Does your agency budget show a Surplus or Deficit? Surplus <br /> Is there a significant change? Yes/No No <br /> Please provide a brief explanation for Surplus or Deficit, and significant changes. <br /> Our 2017 budget shows a surplus of less than $1,000, indicating that we intend to <br /> generate revenue and appropriately use funding so that we are not left with a <br /> deficit. <br /> iv. What is your agency's fiscal year? January 1, 2017 - December 31, 2017 <br /> (Example: July 1, 2016 through June 30, 2017) <br /> Agency Information 1/27/2017 3:48:29 PM II ' ago 9 of 2G <br />