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DocuSign Envelope ID:39EEFC69-D47C-4CE3-8A5C-0A87B55C2CD0 XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> i. 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 /> 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 <br /> 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 /> ii. Does your agency budget show a Surplus or Deficit? Deficit <br /> Is there a significant change? Yes/No Yes <br /> Please provide a brief explanation for Surplus or Deficit, and significant changes. <br /> Agency Information 2/9/2017 11:59:17 AM 8o 8 o If I "'i"" <br />