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DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> program year, current program year, and next program year for the <br /> 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 /> Is there a significant change? Yes/No No <br /> Please provide a brief explanation for Surplus or Deficit, and significant changes. N/A <br /> iii. What is your agency's fiscal year? Oct 1, 2017 - Sept 30, 2018 <br /> (Example: July 1, 2016 through June 30, 2017) <br /> DO NOT SUBMIT THIS PAGE 1/26/2017 11:10:15 AMII'age 16 •r 31 <br />