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DocuSign Envelope ID: FCA96EA6-6080-4E8E-8EFF-B03ECA597827 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> Agency Budget <br /> Ad. Is your agency currently receiving and/or requesting other(non-Human <br /> Services) local (Town of Carrboro, Town of Chapel Hill, Orange County) <br /> government funding? (Yes/N2 <br /> Our agency is not receiving nor requesting any other(non human services) local <br /> (Carrboro, Chapel Hill, Orange County)government funding. <br /> If yes, please list below: <br /> Include all programs that have funding requests/awardsltotals 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 FY1?-18 Source <br /> Award Re uest <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 /> wumemmynnrorrvmmv <br /> Nn <br /> *Add rows or attach additional page, if needed. <br /> Agency Information 1/26/2017 14:54:11 a1/p1 Page g 10 of 22 <br />