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DocuSign Envelope ID: CCFF6125- AA47- 438A- 98CA- B42519499D42 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />County about certification, but there was a technical issue around PHS' prn employees in the <br />County. PHS would like to reinvestigate certification. <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) No <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 />Ex: Affordable Rental <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 />Carrboro Total Funding <br />Not Applicable <br />*Add rows or attach additional page, if needed. <br />ii. 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 />• 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 />Agency Information 1/23/2018 11:00:54 AM Page 12 of 23 <br />