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DocuSign Envelope ID: 28872B9E- 993A- 44CA- 8A5E- OBDA1F6178CB <br />Exhibit A: Provider's Outside Agency Application <br />If yes, is this agency an Grange County Living Wage Certified Employer? <br />If no, please explain. <br />TDAC is solely based on contract employees. <br />h) Agency Budget <br />L 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? fYes/No) Yes <br />If yes, please list below: <br />Include all programs that have funding requestslawards4otals from Carrboro, Chapel Hill, <br />and Or County governments (other than Human Services). DO NOT include federal <br />funding sources, such as CDBG and HOME. <br />Program <br />FYI 6-17 <br />Award <br />FYI 7-18 <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 />Orange County Government <br />$7,000 <br />$15,000 <br />Town of Chapel Hill <br />$7,000 <br />$15,000 <br />Town of Carrboro <br />$5,500 <br />$20,000 <br />Total <br />$195500 <br />$50,000 <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 />Agency Information 1/29/2018 3:34:15 PM Page 10 of 24 <br />