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DocuSign Envelope ID: C5305795- 2DF5- 4A04- B090- 9F458AA520CB <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />Orange County Human Services <br />® Orange County Other (DO NOT Include HOME funding here) <br />o Other Government Grants <br />® Triangle United Way <br />■ State Government <br />0 Federal Government (CDBGIHOMEIetc.) <br />■ Private Foundation Grants <br />o Other Revenue <br />® Expenditures <br />• Compensation <br />• Rent & Utilities <br />• Supplies & Equipment <br />• Travel & Training <br />• Other Expenses <br />iii. Does your agency budget show a Surplus or Deficit? Surplus <br />Is there a significant change? Yes /No No <br />Please provide a brief explanation for Surplus or Deficit, and significant changes. <br />iv. What is your agency's fiscal year? January 1- December 31 <br />(Example: July 1, 2016 through June 30, 2017) <br />Agency Information 1/22/2018 2:17:04 PM P a g e 6 o f 1 5 <br />