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DocuSign Envelope ID: C5C1 1 FD4-56CD-48FD-BBD1 -95F2AFF7112B <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />hj Agency Budget <br />i. 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? (YeslNo) yes <br />If yes, please list below: <br />Include all programs that have funding requestslawards/totals from Carrboro Chapel Hill <br />and Oran le GOWItY governments (other than Human Services) DO NOT include federal <br />funding sources, such as CDBG and HOME. <br />Program <br />FY17 -18 <br />FY18 -19 <br />Source <br />Ex: Affordable Rental <br />Award <br />0 <br />Re oast <br />Rehabilitation <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 Human <br />Services <br />9028 <br />9200 <br />OC Human Services <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 if contains the same <br />information, and in a similar format, as requested in the provided template). <br />Agency Information 1/23/2018 12:09:02 PM Page 1 2 of 27 <br />