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DocuSign Envelope ID:C8F16CD1-FF19-486F-8006-57316D1FCD54 <br /> EXHIBIT A - PROVIDERS OUTSIDE AGENCY APPLICATION <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 /> See Attachment. <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 /> • 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? Yes <br /> Is there a significant change? Yes/No Yes <br /> Please provide a brief explanation for Surplus or Deficit, and significant changes. <br /> FY 15-16 deficit covered by carry over of Stickwork funds. FY16-17 deficit covered by carry over <br /> of Mary Duke Biddle Afterschool grant. <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 /> DO NOT SUBMIT THIS PAGE 2/8/2017 9:36:1.0 AM Page 1 2 ei If 2 0'1 <br />