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DocuSign Envelope ID: DB2FC63F- 0403 - 4403- BF86- OF5CB206F3F3 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <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? (YevNo) No <br />If yes, please list below: <br />Include all programs that have funding requests/awardsftotals from Carrboro, Chapel Hill. <br />and Orange Cour+fy govemments (other than Human Services). DO NOT include federal <br />funding sources, such as CDSG and HOME. <br />Program <br />FYI 7-18 <br />Award <br />FYI 8-19 <br />Request <br />Source <br />Ex: Affordable Rental <br />Rehabilitation <br />0 <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 />*Add rows or attach additional page, if needed. <br />ii. Submit your agency's budges. 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 Budgets are required to define budget amounts for the previous program <br />year, current program year, and next program year for the following categories: <br />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 CDSG funding here) <br />Agency Information 1112/2018 10:05:28 AM Page 12 of 25 <br />