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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 /> Native Hawaiian or other Pacific <br /> Islander 0% 0% 1% <br /> Other 10% 10% 10% <br /> Total 100% 100% 100% <br /> Of the above, how many <br /> Hispanic/Latino 0 3% 5% <br /> Of the above, how many non- <br /> Hispanic/Latino 100% 97% 95% <br /> Total 100% 100% 100% <br /> Age <br /> 0-5 years 0 0 0 <br /> 6-18 years 25% 30% 35% <br /> 19-50 years 65% 60% 55% <br /> 51-61 years 10% 10% 10% <br /> 62+ years 0 0 0 <br /> Total 100% 100% 100% <br /> Geographic Location <br /> Durham City 15% 15% 15% <br /> Durham County 5% 5% 5% <br /> Carrboro 0% 5% 5% <br /> Chapel Hill 20% 20% 20% <br /> Chapel Hill Public Housing Residents <br /> Orange County 15% 15% 15% <br /> Raleigh 20% 20% 20% <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 <br /> Disabled (not elderly) 100% 100% 100% <br /> Homeless 0 0 <br /> People with HIV/Aids 0 0 <br /> Total 100% 100% 100% <br /> Main Application 5/24/2016 9:03:13 AM .. I 0 o of 2 <br />