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DocuSign Envelope ID:7B55B196-3912-4C1A-ADB4-A753058DFEFD XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <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 requestslawardsltotals 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 FYI 6-17 FYI 7-18 Source <br /> Award Request <br /> Ex: Affordable Rental 0 $20,000 Carrboro -Affordable Housing <br /> Rehabilitation <br /> Ex: Agency Administration $15,000 $10,000 Carrboro— Other <br /> Ex. Total $15,000 $35,000 Carrboro Total Funding <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 /> Agency Information 1/26/2017 5:52:39 PM Page 'I 'I of 26 <br />