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DocuSign Envelope ID: oo-98o*3oe55r3Ao8E5 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> Additional Proqram Information <br /> I) Target Population <br /> Complete the following tabiee, with numbers (not percentages) of individuals served and to be <br /> served, to the best of your ability, <br /> Program Target Population Demographics <br /> Actual Estimated Projected <br /> 2015'10 2010-17 2017-18 <br /> Gender <br /> Male 27 35 45 <br /> Female 23 31 40 <br /> Total 50 66 85 <br /> Ethnicity <br /> African-American 16 20 28 <br /> American Indian or Alaska Native 0 <br /> Asian 15 20 25 <br /> Caucasian 2 3 5 <br /> Native Hawaiian or other Pacific Islander <br /> Other: specify_Hispanic 17 23 27 <br /> Total 50 68 85 <br /> Of the above, how many Hispariic/Latino 17 23 27 <br /> Of the above, how many non-Hispanic/Latino 33 43 58 <br /> Total 50 66 85 <br /> Age <br /> 0-5 years <br /> 6-18 years 50 66 85 <br /> 19-50 years <br /> 51+ years <br /> Total 0 0 0 <br /> Geographic Location <br /> Alamance County <br /> Chatham County <br /> Durham County <br /> Wake County <br /> Orange County Breakdown <br /> Chapel Hill Public Housing °20 25 35 <br /> Town of Chapel Hill (Non-Public Housing) °28 37 44 <br /> Town of Carrboro *4 4 6 <br /> Town of Hillsborough <br /> City of Mebane (Orange County) <br /> Orange County (Outside Municipalities) <br /> • A guestimate <br /> Total ~50 66 85 <br /> PROGRAM INFORMATION 1/27/2017 11:04:11 AM Page 1 � of 2 2 <br />