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DocuSign Envelope ID: 07FEE1A8- E83F- 44CF- 99C4- 61A6E4C39BD2 <br />EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION <br />If yes, is this agency an Orange County Living Wage Certified Employer? <br />If no, please explain. <br />TDAC is solely based on contract employees. <br />h) Agency Budget <br />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 <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 <br />FY16 -17 <br />Award <br />FY17 -18 <br />Request <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 />$35,000 <br />Carrboro Total Funding <br />Orange County Government <br />$7,000 <br />$15,000 <br />Town of Chapel Hill <br />$7,000 <br />$15,000 <br />Town of Carrboro <br />$5,500 <br />$20,000 <br />Total <br />$19,500 <br />$50,000 <br />*Add rows or attach additional page, if needed. <br />ii. Submit your agency's budget. You may complete the provided template (separate <br />As 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 />• Private Donations <br />• Program Generated Revenue <br />Agency Information 2/9/2017 4:31:06 PM Page 9 of 22 <br />