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DocuSign Envelope ID: A2273A84- 8827 - 4141- A87E- C8CFF83C3936 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />• Orange County Human Services <br />• Orange County Other (DO NOT Include HOME funding here) <br />o Other Government Grants <br />• Triangle United Way <br />• State Government <br />• Federal Government (CDBG /HOME /etc.) <br />• Private Foundation Grants <br />o Other Revenue <br />Expenditures <br />o Compensation <br />o Rent & Utilities <br />• Supplies & Equipment <br />• Travel & Training <br />• Other Expenses <br />iii. Does your agency budget show a Surplus or Deficit? Breakeven <br />Is there a significant change? Yes /No No <br />Please provide a brief explanation for Surplus or Deficit, and significant changes. <br />Increase in expenses due to significant increase in program participants, demanding <br />increase in staffing and increase use of interpreter services. Insurance expense more <br />than doubled in 2017 -2018 due to new risk coverage requirements from Orange County. <br />iv. What is your agency's fiscal year? January 1, 2018- December 31, 2018 <br />(Example: July 1, 2016 through June 30, 2017) <br />Agency Information 1/23/2018 3:14:24 PM 1 3 3 6 <br />