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DocuSign Envelope ID:72266CE5-DF5A-471 E-B671-CC65C8960691 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <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 /> • 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? Surplus <br /> Is there a significant change? Yes/No No <br /> Please provide a brief explanation for Surplus or Deficit, and significant changes. <br /> We have recorded a slight surplus this fiscal year due to the fact that the rental <br /> units have not needed as many repairs. Many of EmPOWERment's rental units <br /> are older and the surplus will be carried over for any unexpected repairs in the <br /> next fiscal year. <br /> iv. What is your agency's fiscal year? January 1 through December 31 <br /> (Example: July 1, 2016 through June 30, 2017) <br /> For the purposes of this report we have calculated the Agency and Program <br /> Budget on a July to June fiscal year. <br /> Agency Information 1/25/2017 4:42:59 PM P e 1 2 of 2 2 <br />