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DocuSign Envelope ID: E546BA93-2CAA-4121-B91A-3F2107563B4D <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> Additional Program Information <br /> 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 50 250 <br /> Female 50 250 <br /> Total N/A 100 500 <br /> Ethnicity <br /> African-American 111111111= 100 500 <br /> - <br /> American Indian or Alaska Native <br /> Asian <br /> Caucasian <br /> Native Hawaiian or other Pacific Islander <br /> Other: specify <br /> Total N/A 100 500 <br /> Of the above, how many Hispanic/Latino 10 100 <br /> Of the above, how many non-Hispanic/Latino 90 400 <br /> Total N/A 100 500 <br /> Age <br /> 0-5 years <br /> 6-18 years 10OI ........500.. <br /> 19-50 years IM <br /> 51+ years <br /> Total N/A 100 500 <br /> Geographic Location <br /> Alamance County <br /> Chatham County <br /> Durham County <br /> Wake County <br /> Orange County Breakdown <br /> Chapel Hill Public Housing MEd 50 <br /> Town of Chapel Hill (Non-Public Housing) 50 200 <br /> Town of Carrboro 100 <br /> Town of Hillsborough 50 150 <br /> City of Mebane (Orange County) <br /> Orange County (Outside Municipalities) <br /> PROGRAM INFORMATION 1/31/2017 3:24:15 PM P aqP 20 2 f 2 9 <br />