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DocuSign Envelope ID: 17COF518- 9238 - 480E- 96E6- 77F FCC C2626B <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) No <br />If yes, please list below: <br />Include all programs that have funding requestslawardsltotals from Carrboro, Chapel HiII _ <br />and Orange Count governments (other than Human Services). DO NOT include federal <br />funding sources, such as CDBG and HOME. <br />Program FY17 -18 I FYI 8-19 Source <br />Award l Request <br />*Add rows or attach additional page, if needed. <br />ii. Submit your agency's budget. You may complete the provided template (separate <br />xls 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 />• Private Donations <br />• Program Generated Revenue <br />• 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 />- - - -- <br />Agency Information 1/23/2018 4:21:18 PM Page 13 of 25 <br />