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DocuSign Envelope ID: 1007B77C-A009-4AA3-964B-3B03B9585341 <br /> txnibit A-continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> 19-50 years 20% 20% 20% <br /> 51-61 years 5 5 5 <br /> 62+ years 0 0 0 <br /> Total 100% 100% 100% <br /> Geographic Location <br /> Durham City 20% 20% 20% <br /> Durham County 5% 5% 5% <br /> Carrboro 0% 5% 5% <br /> Chapel Hill 10% 10% 5% <br /> Chapel Hill Public Housing Residents <br /> Orange County 15% 15% 15% <br /> Raleigh 25% 25% 25% <br /> Wake County 15% 15% 15% <br /> Total 90% 95% 95% <br /> Income Level —See following chart <br /> (Omit for HS) <br /> < 30%Area Median Income <br /> 31-50% Area Median Income <br /> 51-80% Area Median Income <br /> > 80%Area Median Income <br /> Total 0 0 0 <br /> Special Needs (Omit for HS) <br /> Elderly(Over 62) 0 0 0 <br /> Disabled (not elderly) 100% 100% 100% <br /> Homeless 0 0 0 <br /> People with HIV/Aids 0 0 0 <br /> Total 100% 100% 100% <br /> Program: Adapted Sports: Boccia Ball <br /> Program Beneficiary Demographics <br /> Actual Estimated Projected <br /> 2014-15 2015-16 2016-17 <br /> Gender <br /> Male 19 30 60 <br /> Female 47 75 100 <br /> Total 66 105 160 <br /> Of the females, how many are single- <br /> female Head of Households (Omit for <br /> Human Services) <br /> Ethnicity <br /> African-American 36% 38% 37% <br /> American Indian or Alaska Native 0% 0% 0% <br /> Asian 0% 2% 3% <br /> Caucasian 50% 50% 50% <br /> Main Application 5/24/2016 9:03:13 AM .. • of 2 <br />