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DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> h) Agency Budget <br /> i. 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/No) NO <br /> If yes, please list below: <br /> Include all programs that have funding requests/awards/totals from Carrboro, Chapel <br /> Hill, and Orange County governments (other than Human Services). DO NOT include <br /> federal funding sources, such as CDBG and HOME. <br /> Program FY16- FY17-18 Source <br /> 17 Request <br /> Award <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 /> *Add rows or attach additional page, if needed. <br /> ii. Submit your agency's budget. You may complete the provided template <br /> (separate xls file) or you may submit your own budget file (as long as it <br /> contains the same information, and in a similar format, as requested in the <br /> provided template). <br /> Agency Budgets are required to define budget amounts for the previous <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 /> Agency Information 2/9/2017 1:10:02 PM I: uge 12 o If 10 <br />