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DocuSign Envelope ID: 80124B29- E4DA- 4BOD- A879- D287FCF3F3CA <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? (Yes /No) Yes <br />If yes, please list below: <br />Include all programs that have funding requests /awards /totals from Carrboro, Chapel Hill, <br />and Orange County governments (other than Human Services). DO 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 />Orange County Social Justice <br />Funds rent and utilities <br />$11,340 <br />0 <br />RSC was asked to apply by Orange <br />County Mana er <br />$11,340 <br />0 <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 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 CDBG funding here) <br />• Orange County Human Services <br />Agency Information 1/18/2018 1:56:21 PM Page 13 of 26 <br />