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DocuSign Envelope ID: C0131349A6 -D1E9- 42DE- 8E8D- 7583E683E1E2 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />Does this agency pay permanent employees a minimum living wage? (Yes I No) yes <br />If yes, is this agency an Grange County Living Wage Certified Employer? yes <br />If no, please explain. <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? (YeslNo) No <br />If yes, please list below: <br />Include all programs that have funding requestslawardsltotals from Carrboro, Chapel Hill, <br />and Orange County governments (other than ,Human Services). LSO NOT include federal <br />funding sources, such as CDBG and HOME. <br />Program <br />FY17 -18 <br />Award <br />FY18 -19 <br />Request <br />Source <br />Carrbo_­ro - Affordable Housing <br />Ex: Affordable Rental <br />Rehabilitation <br />0 <br />, <br />$20,000 <br />Ex: Agency Administration _l <br />Ex. Total <br />_ $15,000 <br />$15,000 <br />$1_ 5,000 <br />$35,000 <br />Carrboro — Other <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 Information 1/2112018 12:07:58 PM Page 5 of 17 <br />