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DocuSign Envelope ID: D3ADCOFO-56OB-45AA-A3EA-B65E3A3AO6DE XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> ■ Chapel Hill Human Services <br /> • Chapel Hill Other (DO NOT include CDBG funding here) <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 (CDBGIHOMEIetc.) <br /> ■ Private Foundation Grants <br /> o Other Revenue <br /> Expenditures <br /> o Compensation <br /> o Rent & Utilities <br /> o Supplies & Equipment <br /> o Travel & Training <br /> o Other Expenses <br /> iii. Does your agency budget show a Surplus or Deficit? Surplus <br /> Is there a significant change? <br /> Please provide a brief explanation for Surplus or Deficit, and significant changes. <br /> Please see all comments explaining our surplus on our budget document. <br /> iv. What is your agency's fiscal year? September 1, 2016—August 31 , 2017 <br /> (Example: July 1, 2016 through June 30, 2017) <br /> Agency Information 1/30/2017 4 15:08 PM N : r 1 0 i 19 <br />