Orange County NC Website
DocuSign Envelope ID: 74839431 - 9216- 429F- BFA4- 2AC6473BD9D3 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />h) Agency Budget <br />L Is your agency currently receiving and/or requesting other (non -Human <br />Services) local (Town of Carrboro, Town of Chapel Hill, Orange County) <br />government funding? (YeslNo) Yes <br />If yes, please list below: <br />Include all programs that have funding requestslaward&4otals from Carrboro Chapel Hill <br />and Orange County governments (other than Human Services). DO NOT include federal <br />funding sources, such as C BG and HOME. <br />Program FY17 -18 FY18 -19 Source <br />Award Request <br />Ex: Affordable Rental 0 $20,000 Carrboro - Affordable Housing <br />Rehabilitation <br />Ex: Agency Administration $15,000 $15,000 Carrboro -- Other <br />Ex. Total $15,000 $35,000 Carrboro Total Funding <br />Partner Abuse Intervention $1,875 $1,875 1n -kind donation of space for <br />meetings at Southern Human <br />Services Buildin <br />I <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 />• 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 />a Compensation <br />* Rent & Utilities <br />Q Supplies & Equipment <br />Agency Information 1/23/2018 11-18:32 AM Page 12 of 30 <br />