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DocuSign Envelope ID: DDOCF1362 -8EDD- 41357- ACF6- 9C98BO78AA95 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 <br />FY16- FY17-18 <br />17 Request <br />Award <br />Source <br />Ex: Affordable Rental <br />Rehabilitation <br />0 <br />$20,000 <br />Carrboro - Affordable Housing <br />Ex: Agency Administration <br />$15,000 <br />$15,000 <br />Carrboro — Other <br />Ex. Total <br />$15,000 <br />$35,0001 <br />Carrboro Total Funding <br />N/A <br />N/A <br />N/A <br />N/A <br />*Add rows or attach additional page, if needed. <br />ii. Submit your agency's budget. You may complete the provided template <br />(separate xis 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 />r Revenues <br />• Private Donations <br />• Program Generated Revenue <br />Agency Information 1/31/2017 10:54:56 AM Page 6 of 26 <br />