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DocuSign Envelope ID: 80124B29-E4DA-4BOD-A879-D287FCF3F3CA <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />Agency Budget <br />Operating Budget for Entire Agency <br />AGENCY NAME, <br />AGENCY REVENUE <br />Private Donations <br />Agency Generated Revenue (fees) <br />Local Government Grants: <br />Human Services - Toym of Carrboro <br />Other - Town of Can-lboro <br />Human Services - Tom of Chapel Hill <br />Other- Tom of Chapel Hill <br />Human Services - Orange County <br />Other - Orange County <br />Other - Town of Hillsborough <br />Other Government Grants <br />Triangle United Way <br />State Government <br />Federal Government (CDBG/HOME/etc.) <br />Private Foundation Grants <br />Other Revenue <br />Total Agency Revenue <br />AGENCY EXPENSES <br />Compensation <br />Rent & Utilities <br />Supplies & Equipment <br />Travel & Training <br />Other Expenses: <br />Total Agency Expenses <br />SURPI-MI(DEFICIT) FOR PERIOD <br />FY 2018 -19 Agency Budget <br />SuDDort Center <br />I S I S - I S I <br />Agency Information 1/18/2018 1:56:21 PM Page 15 of 26 <br />Actual <br />2016-17 <br />Estimated <br />2017-18 <br />Projected <br />2018-19 <br />Percent <br />Change <br />$ <br />12,600 <br />S <br />14,260 <br />$ <br />16,000 <br />12% <br />$ <br />$ <br />$ <br />$ <br />6,000 <br />$ <br />$ <br />$ <br />$ <br />$ <br />6,000 <br />$ <br />$ <br />5,000 <br />- <br />11,340 <br />- <br />-100% <br />$ <br />$ <br />$ <br />0 <br />$ <br />$ <br />$ <br />0 <br />$ <br />5 <br />$ <br />0 <br />$ <br />S <br />$ <br />- <br />01 <br />$ <br />12,000.00) <br />$ <br />15,000.00 <br />$ <br />15,000.00 <br />$ <br />- <br />$ <br />- <br />$ <br />0 <br />$ <br />24,600 <br />18,500 <br />$ <br />$ <br />40,600 <br />22,000 <br />$ <br />S <br />48,000 <br />24,000 <br />18% <br />9% <br />- <br />$ <br />1-1,340 <br />$ <br />13,000 <br />15% <br />3,600 <br />$ <br />5,000 <br />4:000 <br />-20% <br />1 S)00: <br />$ <br />1,000 <br />$ <br />- <br />-100% <br />S <br />1,500 <br />1260 <br />S <br />7.00G <br />456% <br />S <br />24.600 <br />S <br />40.600 <br />1 S <br />48,000 <br />18%1 <br />I S I S - I S I <br />Agency Information 1/18/2018 1:56:21 PM Page 15 of 26 <br />