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DocuSign Envelope ID: EA54395E-EA79-461 B-8A4A-AODF56E9A02D <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> h) Agency Budget <br /> i. Is your agency currently receiving and/or requesting other (non-Human Services) <br /> local (Town of Carrboro, Town of Chapel Hill, Orange County) government <br /> funding? (Yes/No) No <br /> If yes, please list below: <br /> Include all programs that have funding requests/awards/totals 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 FY17-18 Source <br /> Award Request <br /> Charitable Companion Care 4,000 6,000 Town of Carrboro <br /> Charitable Companion Care 4,000 6,000 Town of Chapel Hill <br /> Charitable Companion Care 6,000 8,000 Orange County <br /> • <br /> *Add rows or attach additional page, if needed. <br /> ii. Does your agency budget show a Surplus or Deficit? Neither <br /> Is there a significant change?Yes/No No <br /> iii. What is your agency's fiscal year? July 1, 2016 throucih June 30, 2017 <br /> Agency Information 1/31/2017 3:19:07 PM <br />