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DocuSign Envelope ID: 4B292955- 9A36- 47C6- BDDE- 4E9CDOBA074D <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />h) Agency Budget <br />i. 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 />Teen Court <br />12,099 <br />12,099 <br />Orange County - JCPC 30% match <br />Community Service <br />27,261. <br />27,261 <br />Orange County - JCPC 30 %match <br />Total <br />39,360 <br />39,360 <br />Orange County Total Funding <br />*Add rows or attach additional page, if needed. <br />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 />• 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 />Agency Information 1/19/2018 2:38:17 PM P a g e 1 2 o f 2 6 <br />