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DocuSign Envelope ID: FCA96EA6-6080-4E8E-8EFF-B03ECA597827 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> Ail. Submit your agency's budget. You may complete the provided template (separate <br /> xis 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 /> 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 /> A.iii. Does your agency budget show a Surplus or Deficit? <br /> Surplus from 2016 <br /> Is there a significant change?Yes/No <br /> Please provide a brief explanation for Surplus or Deficit, and significant changes. <br /> There is a change in our budget due a new management team, a recent focus on <br /> stewardship, and the merger of the Durham and Chapel Hill Boys & Girls Clubs. Orange <br /> county budget information is not fully represented in our full 2016 budget due to a late fall <br /> merger. However, they are included in 2017. <br /> A.iv. What is your agency's fiscal year? <br /> (Example: July 1, 2016 through June 30, 2017) <br /> The previous Chapel Hill organization (Boys & Girls Club of Eastern Piedmont)operated <br /> from July 1, 2016. However, the Boys & Girls Clubs of Durham and Orange Counties <br /> operates January 1, 2017 to December 31, 2017. <br /> Agency Information 1/26/2017 14:54:11 al/pi Page 11 of 22 <br />