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DocuSign Envelope ID: 1632E805-38D3-49DF-9836-981006B20F64 XHIBIT 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 /> LProgram Target Population Demographics <br /> Actual Estimated Projected <br /> 2015-16 2016-17 <br /> 2017-18 <br /> Gender <br /> Male 45% 45% <br /> t 45% <br /> Female 55% 55% 55% <br /> Total El 00% 100% 100% <br /> Ethnicity <br /> African-American 1 40 30 40 <br /> American Indian or Alaska Native 10 15 10 <br /> Asian 5 10 5 <br /> Caucasian 40 40 40 <br /> I 5 <br /> Native Hawaiian or other Pacific Islander 1 5 5 <br /> Other: specify <br /> 1 <br /> Total 100 I 100 100 <br /> Of the above, how many Hispanic/Latino unknown unknown unknown <br /> Of the above, how many non-Hispanic/Latino unknown unknown unknown <br /> Total 5,000 6,500 8,000 <br /> _ <br /> Age <br /> 0-5 years unknown 500 1,000 <br /> 6-18 years unknown 2,500 2,500 <br /> 19-50 years unknown 1,500 2,000 <br /> 51+ years unknown 2,000 2,500 <br /> Total 0 6,500 8,000 <br /> PROGRAM INFORMATION 1/31/2017 4:15:48 PM P a q a 15 o f 2 2 <br />