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DocuSign Envelope ID: CCFF6125- AA47- 438A- 98CA- B42519499D42
<br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
<br />• Rent & Utilities
<br />• Supplies & Equipment
<br />• Travel & Training
<br />• Other Expenses
<br />iii. Does your agency budget show a Surplus or Deficit? No (balanced)
<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 -Dec 31, 2018
<br />(Example: July 1, 2016 through June 30, 2017)
<br />Agency Budget
<br />Operating Budget for Entire Agency
<br />AGENCY NAME: Piedmont Health Services. Inc.
<br />AGENCY REVENUE
<br />Private Donations
<br />Agency Generated Revenue lfees)
<br />Local Government Grants:
<br />Human Services -Town of Carrboro
<br />Other - Town of Carrboro
<br />Human Services -Town of Chapel Hill
<br />Other - Town of Chapel Hill
<br />Human Services - Orange County
<br />Other- Orange County
<br />Other - Town of Hillsborough
<br />Other Government Grants
<br />Triangle United Way
<br />State Government
<br />Federal Government (CaBGfHOME ?etc.)
<br />Private Foundation Grants
<br />Other Revenue
<br />Total Agency Revenue
<br />AGENCY EXPENSES
<br />Compensation
<br />Rent R Utilities
<br />Supplies & Equipment
<br />Travel 9 Training
<br />Other Expenses:
<br />Total Agency Expenses
<br />SURPLUS!(DEFICIT) FOR PERIOD
<br />Actual FY1-6
<br />Estimated EY17
<br />Projected FY18
<br />Percent
<br />Change
<br />$ 349,615
<br />$
<br />20.256
<br />$
<br />-
<br />- 100%
<br />$ 38,135,519
<br />$
<br />43,884,683
<br />$
<br />55,777,152
<br />27%
<br />$ 3,000
<br />$
<br />5,000
<br />$
<br />15,000
<br />200%
<br />$ -
<br />$
<br />-
<br />$
<br />0
<br />$ 2,000
<br />$
<br />2.000
<br />$
<br />15,000
<br />650%
<br />$ -
<br />$
<br />-
<br />$
<br />-
<br />0
<br />$ 11,000
<br />$
<br />16,500
<br />$
<br />16,500
<br />0%
<br />$
<br />$
<br />$
<br />0
<br />$
<br />$
<br />$
<br />0
<br />$
<br />$
<br />$
<br />0
<br />$ 543,506
<br />$
<br />360,607
<br />$
<br />517,533
<br />$ 0.44
<br />$ 8,879,101
<br />$
<br />10,901,684
<br />$
<br />9,121.885
<br />$ 0.161
<br />$ 1,017,000
<br />$
<br />1,301,268
<br />$
<br />916,000
<br />$ 0.30
<br />$ 1,254,240
<br />$
<br />869,058
<br />$
<br />441,636
<br />$ 0.49
<br />$ 50,194,981
<br />$ 28,838,007
<br />$57,361,056
<br />$ 33,362,859
<br />$66,820,706
<br />$ 37,609,040
<br />16%
<br />13%
<br />$ 945,792
<br />$
<br />1,038,516
<br />$
<br />2,527,171
<br />143%
<br />$ 1461240
<br />$
<br />4,760,000
<br />$
<br />4,774.803
<br />0%
<br />$ 515,918
<br />$
<br />479,535
<br />$
<br />464,902
<br />-3%
<br />16.340,805
<br />$
<br />18,589,472
<br />$
<br />21,444,790
<br />15 °I¢
<br />$ 50,101,762
<br />$58,230,382
<br />$66,820,706
<br />15 °Ia
<br />$ 93,219 1 $ (869,326) $ - 1 1{?0
<br />Agency Information 1/23/2018 11:00:54 AM Page 13 of 23
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