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DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF 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 <br /> be served, to the best of your ability, <br /> Program Target Population Demographics <br /> Actual Estimated Projecte <br /> 2015-16 2016-17 d <br /> 2017-18 <br /> Gender <br /> Male 50 50 55 <br /> Female 25 25 30 <br /> Total 75 75 85 <br /> Ethnicity <br /> African-American 15 14 18 <br /> American Indian or Alaska Native <br /> Asian <br /> Caucasian 43 44 45 <br /> Native Hawaiian or other Pacific Islander <br /> Other: specify 17 17 22 <br /> Total 75 75 0 <br /> Of the above, how many Hispanic/Latino 12 15 18 <br /> Of the above, how many non-Hispanic/Latino 63 <br /> Total 75 75 85 <br /> Age <br /> 0-5 years 0 25 40 <br /> 6-18 years 67 44 38 <br /> 19-50 years 7 6 7 <br /> 51+ years <br /> Total 75 75 85 <br /> Geographic Location <br /> Alamance County 100 95 120 <br /> Chatham County 90 0 0 <br /> Durham County 120 110 125 <br /> Wake County 0 15 45 <br /> DO NOT SUBMIT THIS PAGE 1/26/2017 11:10:15 AMIII'age 24 r 31 <br />