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DocuSign Envelope ID: FCA96EA6-6080-4E8E-8EFF-B03ECA597827 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> Additional Program Information <br /> c) 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 <br /> Population <br /> Demographics <br /> Actual Estimated Projected <br /> 2015-16 2016-17 2017-18 <br /> Gender <br /> Male 284 290 <br /> Female 169 200 <br /> Total 0 453 490 <br /> Ethnicity <br /> African-American 386 386 <br /> American Indian or Alaska Native <br /> Asian <br /> Caucasian 6 29 <br /> Native Hawaiian or other Pacific Islander <br /> Other: specify hispanic, other 51 75 <br /> Total 0 453 490 <br /> Of the above, how many Hispanic/Latino 50 75 <br /> Of the above, how many non-Hispanic/Latino 403 415 <br /> Total 0 453 490 1 <br /> Age <br /> 0-5 years 0 <br /> 6-18 years 453 490 <br /> 19-50 years <br /> 51+years <br /> Total 0 453 490 <br /> PROGRAM 11VORMATION1/26/2017 14:54:11 alipl Pa g e 17 of 22 <br />