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Page 11 of 23 <br />i. Is your agency currently receiving and/or requesting other (non-Human <br />Services) local (Town of Carrboro, Town of Chapel Hill, Orange County) <br />government funding?(Yes/No)Yes <br /> <br />If yes, please list below. Include all programs that have funding requests/awards/ <br />totals from Carrboro, Chapel Hill, and Orange County governments (other than <br />Human Services). DO NOT include federal funding sources, such as CDBG and <br />HOME. <br />Program FY17-18 <br />Award <br />FY18-19 <br />Request Source <br />2 repair projects in Carrboro $2,334 $0 Carrboro – Affordable Housing <br />Special Revenue Fund <br />7 new homes in Northside $105,000 $0 Chapel Hill – Affordable Housing <br />Development Reserve <br />Sewer and other work at 326 <br />McMasters Street <br />$25,000 $0 Chapel Hill – Affordable Housing <br />Development Reserve <br />Planning, development, and <br />infrastructure for 24 senior housing <br />units in Hillsborough <br />$425,000 $500,000 Orange County – Affordable <br />Housing Bond <br />Planning, development, and <br />infrastructure for 24 senior housing <br />units in Hillsborough <br />$0 $125,000 Hillsborough – Other <br />Total $557,334 $625,000 <br />*Add rows or attach additional page, if needed. <br /> <br />ii.Submit your agency’s budget. You may complete the provided template <br />(separate xls file) or you may submit your own budget file (as long as it <br />contains the same information, and in a similar format, as requested in the <br />provided template). Agency Budgets are required to define budget amounts <br />for the previous program year, current program year, and next program <br />year for the following categories: <br />x 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 /> Chapel Hill Other (DO NOT include CDBG funding here) <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 /> Federal Government (CDBG/HOME/etc.) <br /> Private Foundation Grants <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />DocuSign Envelope ID: 1263366F-0902-4D24-AE16-FC2EBB866669