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DocuSign Envelope ID:4FF28E49-EE56-4A40-9331-F55AA8A05998 <br /> EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <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 /> ■ 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 (CDBG/HOME/etc.) <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 /> 0 <br /> iii. Does your agency budget show a Surplus or Deficit? Surplus <br /> Is there a significant change? Yes/No No <br /> Please provide a brief explanation for Surplus or Deficit, and significant changes. <br /> ATI's budget for 2017 shows a surplus in spite of$27,000 in budget cuts, due to a major <br /> increase in fundraising efforts in the second half of 2017 to help offset unexpected <br /> financial losses. <br /> iv. What is your agency's fiscal year? Jan 1, 2017 through Dec 31, 2017 <br /> (Example: July 1, 2016 through June 30, 2017) <br /> Agency Information 1/23/2018 10:01:04 AM P a g e 1 2 o f 2 4 <br />