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DocuSign Envelope ID: 1327919D -9891- 4603- B056- 5CA1EBBFDF23 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />g) 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? (YeslNo) no <br />If yes, please list below: <br />Include all programs that have funding requests/awards/tota ls from Carrboro, Chapel Hill, <br />and Or "e 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 />Ex: Affordable Dental <br />Rehabilitation <br />0 <br />$20,000 <br />Carrboro - Affordable Housing <br />Ex: Agency Administration <br />$15,000 <br />$15, 000 <br />Carrboro — Other <br />Ex. Total <br />$15,000 <br />$35,000 <br />1 Carrboro Total Funding <br />Human Services <br />$17,500 <br />$20,000 <br />Orange County <br />Add rows or attach additional page, if needed. <br />ii. Subunit your agency's budget. You may complete the provided template (separate <br />xis 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 />Agency Information 1/22/2018 1 :39:57 PM Page 12 of 25 <br />