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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 /> < 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) 10% 10% 10% <br /> Homeless 0 0 <br /> People with HIV/Aids 0 0 <br /> Total 10% 10% 25% <br /> Main Application 5/24/2016 9:03:13 AM Pa I 2 of 2 <br />