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DocuSign Envelope ID: C47D73DC -CC50- 4723 - 8253- AE01785E7FAA <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />• Orange County Human Services <br />• Orange County Other (DO NOT Include HOME funding here) <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 />• Expenditures <br />o Compensation <br />o Rent & Utilities <br />• Supplies & Equipment <br />• Travel & Training <br />• Other Expenses <br />iii. Does your agency budget show a Surplus or Deficit? Surplus <br />Is there a significant change? Yes /No No <br />Please provide a brief explanation for Surplus or Deficit, and significant changes. <br />iv. What is your agency's fiscal year? January 1, 2018 — December 31, <br />2018 <br />(Example: July 1, 2016 through June 30, 2017) <br />Agency Information 1/23/2018 1:53:53 PM ° - ,: e 1 2 c, o <br />