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DocuSign Envelope ID:E522BFFC-A634-4A11-A162-195A3BE957A4 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <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 /> iii. Does your agency budget show a Surplus or Deficit? Surplus <br /> Is there a significant change?Yes/No No <br /> Please provide a brief explanation for Surplus or Deficit, and significant changes. <br /> Actual hospice patient day volume was higher than budgeted. <br /> iv. What is your agency's fiscal year? July 1 , 2016 through June 30, 2017 <br /> (Example: July 1, 2016 through June 30, 2017) <br /> DO NOT SUBMIT THIS PAGE 1/25/2017 11:09:42 AM Page 6 of <br />