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DocuSign Envelope ID: DlA09OF6-2A4E-4FOB-9FB7-92FFFC9El3D2 XHIBIT A: <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> Schedule of Receipts and Expenditures <br /> For Agencies with Revenues Less than$500,OOD <br /> Purpose:This form Is—agencies�nith receipts less Ihan$6WAD that do not have a rmancial audit for a flriandal report),prepared by a certified <br /> public accountant(CFA]Am agency does not need to cOnplete this form if it has a prepared audltlrepod a.can si�7mit for the calendar year and ng <br /> December 31,2U76 orthe fiscal year ending June 30.2017.Agencies with receipts totaling$500,000,from any source,must submit a CPA- <br /> certified finandal audn. <br /> Directions:Tab through each field to enter information.The ReceiptrdAmounts columns will Calculate totals for each sectionlsubsecton row.You <br /> wilt oe unable to r[odl Pocked cells. <br /> �Aczencv en fnfo rmatlon Name: fnc. <br /> ailin Address 825A N.Estes Lk enc Fiscal Year End: mrrddc 6f3>712Ut7 <br /> 2. Proparer.p��u 5wo n,�s Employee arrawAnnvsreucwcu xru THE ooraaFCreat: p Y CPAIAccountaart <br /> Name of Pre rer. Tike Barron <br /> Pre hers rrde. Bookkee -r <br /> Da 'me Phone Number. 919-417-6M <br /> t snail Address: tikx& c"izw <br /> 3. Recei <br /> ndin Source Pu DollarAmount <br /> Foundations Fu 8 Trust Cwts FundlR far prngrams 120.000 <br /> Non refit 6 aruzatlan Grants Fundin for rams 102 827 <br /> IndMdual Business Conalbutions Funding for .rams 33 413 <br /> Lace)Gavamment Contrails rams <br /> for rams <br /> School Grants Funding for 53 087 rams 53 000 <br /> United CFC Conhibuiians Fundin for programs 6 371 <br /> Rental income Funding for rams(Boomerang rents one pMrarn spa ce 3.15.0: <br /> during the sr3hW y ear to the Chapel Hill-Carrhoro YMCAfcr <br /> their after srdwd outreach Prograrn-ilarntaa students in <br /> ubllc hatch <br /> Total Receipts: 373,828 <br /> 4. 5xpInditures <br /> Parson C o DollarAmourrt <br /> e9 1 <br /> Contracted Services 14,858 <br /> a Total PersonrrelfCnMraeted Services Costs: $ 214,507 <br /> Office Su Iles&Materials <br /> Servic 2 049 <br /> e fielated Su Vies 1 498 <br /> b Total Su IIas&material Costs: $ 3 547 <br /> Travel 47 <br /> Communications&Posta 9 <br /> Utilities 1.901 <br /> 1 944 <br /> Printin &Binding Re i 603 t&MaIntenance e03 <br /> Meetin Confamnce Ex nse - <br /> Ein h e'rrdinin notravei 505 <br /> CiassiFred Advertisin <br /> In-State Board Moubno Exoenses <br /> c T aI Hon•Rxed[f rah ift nse: $ 5768, <br /> Office Rent Land Buildin s ate_ 17 1100 <br /> Furniture Rental - _ <br /> _Equip,ment Rental Phones Computers.etc. <br /> Vahicle Rental <br /> Dues&Subscrintons 864 <br /> insurance s Bonin S 136 <br /> BookslLibra Reference MaLerFa& <br /> Mort a e Princi i Interest and Bank Fees 40 <br /> Id Total Fixed Charges&Other Expenses: $ 26 940 <br /> Building a Improvements <br /> Leasehold I mprovqements <br /> Fumiturelhion-Oom ter Equip.,5500+per item _ <br /> Cam ker E ui entfPrinters$5W+ r item 9 <br /> Fumi€urelE i under$50D per item <br /> e atal P e &E ui ment O S 9=1 <br /> Purchase of Services <br /> Corrects Wth Serviee praMars <br /> Sb ndslScholarshi onusesGrents <br /> Total Serulemicontraets: S <br /> Website development wabste development and maintenance 2.950 <br /> Marketing Brodures event invitations 838 <br /> Otherexpense _ Transta6ah(S795);Conferences SW etechiciar S85 23p <br /> Food Ar S.onianizaton students receive tree meals,snacks 1.838 <br /> Total Otlfer f x nses 5 6.556 <br /> Total Expenditures ISlurn of subtotals a tlrrau h $ 265,898 <br /> unex eroded cash balance do NOT use with reimbursement rants <br /> E3e innin of me Year cash halan $ <br /> End of th;Q- S 107 833 <br /> Date1 d <br /> 7'AMI PFEIrER <br /> Pint Name <br />