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DocuSign Envelope ID: 7A9252AF- OE3A- 47EE- A4F6- 2A3D9DF527FF <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />If yes, is this agency an Orange County Living Wage Certified Employer? Yes <br />h) Agency Budget <br />ii. Is your agency currently receiving and/or requesting other (non -Human Services) <br />local (Town of Carrboro, Town of Chapel Hill, Orange County) government funding? <br />Yes <br />If yes, please list below: <br />Include aU programs that have funding requests/awards4otals from Carrboro, Chapel Hill, and <br />Orange County governments (other than Human Services). DO NOT include federal funding <br />sources, such as CDBG and HOME. <br />Program <br />FY17 -18 <br />Award <br />FY18 -19 <br />Request <br />Source <br />Northside /Pine Knolls <br />Community Plan <br />Implementation (Housing <br />Advocacy Program) <br />$40,000 <br />$45,000 <br />Town of Chapel Hill - Affordable <br />Housing Fund <br />*Add rows or attach additional page, if needed. <br />ii. Submit your agency's budget. You may complete the provided template (separate <br />xis 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 />See following page. <br />iii. Does your agency budget show a Surplus or Deficit? Small surplus last year <br />Is there a significant change? No <br />Please provide a brief explanation for Surplus or Deficit, and significant changes. <br />Our budget from last year shows a small surplus of $20,000 used to help build safety <br />reserves for the Jackson Center. <br />iv. What is your agency's fiscal year? July 1, 2018 - June 30: 2019 <br />(Example: July 1, 2016 through June 30, 2017) <br />