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DocuSign Envelope ID: 10F0B4DA-C8B5-4AB3-9AFA-939AE0010B18 (HIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> g) Living Wage <br /> Does this agency pay permanent employees a minimum ti ri.p wva, ? (Yes/No) Yes <br /> If yes, is this agency an ,,g Count' L;ivifa 1,.. ge 'Hie I, . i1? Imo <br /> If no, please explain. <br /> We will plan to submit for certification this spring. We had never considered being certified because <br /> we have never needed certification and have always prioritized a living wage for our employees. <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) Yes mm <br /> If yes, please list below: <br /> Include all programs that have funding requests/awards/totals from Carrboro, Chapel HA <br /> and Orancie 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 /> Implementing the $40,000 $45,000 Chapel Hill —Affordable Housing <br /> NorthsidefPine Knolls Trust Fund (Note: request this <br /> Community Plan (Housing year is from CDBG, not a local <br /> Advocacy Program) source, but still included the <br /> request amount here) <br /> *Add rows or attach additional page, if needed, <br /> II. 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 /> • Rent & Utilities <br /> • Supplies & Equipment <br /> Agency Information 1/31/2'©17 10:50:57 AM <br />