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DocuSign Envelope ID: FOFFD659- 4159- 4D4C- 82FD- FF8E51A5A7E4 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />If no, please explain. <br />Agency Budget <br />L 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? fYes/No) No <br />If yes, please list below: <br />Include all programs that have funding requests/awards/totals from Carrboro. Chapel Hill, <br />anc!_Orange County governments (other than Human Services). DO NOT include federal <br />funding sources, such as CDBG and HOME. <br />Program <br />FYI 7-18 <br />FY18 -19 <br />Source <br />Award <br />Request <br />Ex, Rental <br />0:. <br />$20,000 <br />Cari boro - Affordable:: Housing <br />Rehabilitation <br />Ex Agency Administration <br />$154000 <br />$15,000 <br />- Carrboro Other' <br />Ex. Total <br />$15,000 <br />$35,000 <br />Carrboro Total Funding <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 />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 />Agency Information 1/22/2018 5:50:18 PM P a g e 1 2 o f 4 7 <br />