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DocuSign Envelope ID: B67A2C26-3304-4095-BB1C-73A2BC4A569A <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> k) Include any other pertinent information. <br /> n/a <br /> Additional Program Information <br /> I) Target Population <br /> Complete the following tables, 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 /> 2015-16 2016-17 2017-18 <br /> Gender <br /> Male 15 15 15 <br /> Female 17 34 34 <br /> Total 32 49 49 <br /> Ethnicity <br /> African-American 29 38 43 <br /> American Indian or Alaska Native 0 0 0 <br /> Asian 0 8 4 <br /> Caucasian 2 2 2 <br /> Native Hawaiian or other Pacific Islander 1 1 0 <br /> Other: specify 0 0 0 <br /> Total 32 49 49 <br /> Of the above, how many Hispanic/Latino 0 0 0 <br /> Of the above, how many non-Hispanic/Latino 32 49 49 <br /> Total 32 49 49 <br /> Age <br /> 0-5 years 2 0 0 <br /> 6-18 years 3 9 9 <br /> 19-50 years 5 7 7 <br /> 51+years 22 33 33 <br /> Total 32 49 49 <br /> Geographic Location <br /> Alamance County 0 0 0 <br /> Chatham County 0 0 0 <br /> Durham County 0 0 0 <br /> Wake County 0 0 0 <br /> Orange County Breakdown <br /> Chapel Hill Public Housing 0 0 0 <br /> Town of Chapel Hill (Non-Public Housing) 14 38 15 <br /> Town of Carrboro 7 6 6 <br /> Town of Hillsborough 7 4 13 <br /> City of Mebane (Orange County) 4 1 10 <br /> Orange County(Outside Municipalities) 0 0 5 <br /> Total 32 49 49 <br /> Work Statement <br /> m) Complete the Work Statement Chart to describe the work to be performed. <br /> This chart is used to document program activities, program goals, performance measures, <br /> and actual results. (Add more rows as needed) If this is a new program, you will only <br /> DO NOT SUBMIT THIS PAGE 1/31/2017 2:31 :06 PM Page 15 of °'f <br />