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DocuSign Envelope ID: E865EBC7-DCBB-4CE6-A224-13D663E29E12 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <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 /> , <br /> Actual Estimated Projected <br /> 2015-16 2016-17 2017-18 <br /> Gender <br /> ______., <br /> Male 112 102 <br /> 108 <br /> Female 709 623 667 <br /> Total 821 725 775 <br /> Ethnicity <br /> African-American 101 100 [ 110 <br /> American Indian or Alaska Native 2 2 2 <br /> Asian 29 25 28 <br /> Caucasian 178 170 180 <br /> Native Hawaiian or other Pacific Islander 0 0 0 <br /> Other: Unknown, Bi-Racial, Nigerian, Thai, <br /> Latino (also noted below) 511 428 455 <br /> Total 821 725 775 <br /> Of the above, how many Hispanic/Latino 34 35 35 <br /> Of the above, how many non-Hispanic/Latino 787 690 740 <br /> Total 821 725 775 <br /> Age <br /> 0-5 years 0 0 <br /> 0 <br /> years 1 2 2 <br /> 19-50 years 616 544 581 <br /> 51+ years 204 179 192 <br /> Total 821 725 IIIIIIIIBZII <br /> Geographic Location <br /> Alamance County 7 5 5 <br /> Chatham County 13 20 20_.... . <br /> Durham County 47 40 40 <br /> Wake County 18 1....w1 5 15 <br /> Orange County Breakdown <br /> Chapel Hill Public Housing Unknown Unknown Unknown <br /> Town of Chapel Hill (Non-Public Housing) 271 270 270 <br /> Town of Carrboro 55 55 55 .... <br /> Town of Hillsborough 34 35 35 <br /> City of Mebane (Orange County) 19 20 20 <br /> Orange County(Outside Other/Unklntown 304 I 210 55 <br /> 0 <br /> 260 <br /> PROGRAM INFORMATION 1/30/2017 4:02:21 PM 1::' A cj c 3 0 0 f <br />