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DocuSign Envelope ID: D3ADCOFO-56OB-45AA-A3EA-B65E3A3AO6DE 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) Yes <br /> If yes, please list below: <br /> Include all programs that have funding requests/awards/'totals 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 $15,000 Carrboro—Other <br /> Ex. Total $15,000 $35,000 Carrboro Total Funding <br /> Weekend Meal Backpack $4,000 $12,000 Town of Chapel Hill <br /> Program <br /> Weekend Meal Backpack $5,000 $12,000 Town of Carrboro <br /> Program <br /> Weekend Meal Backpack $5,000 $12,000 Orange County <br /> Program <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 /> o Private Donations <br /> o Program Generated Revenue <br /> o Local Government Grants <br /> ■ Carrboro Human Services <br /> ■ Carrboro Other <br /> Agency Information 1/30/2017 4:15:08 PM P a g e 9 of 19 <br />