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DocuSign Envelope ID:E522BFFC-A634-4A11-A162-195A3BE957A4 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> Additional Proqram 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 /> Actual Estimated Projected <br /> 2015-16 2016-17 2017-18 <br /> Gender , <br /> Male 51 38 40 <br /> Female 63 56 59 <br /> Total 114 94 99 .. <br /> Ethnicity ,, 1 <br /> African-American 12 0 0 ., <br /> American Indian or Alaska Native 0 0 0 <br /> Asian 0 2 3 <br /> Caucasian 89 84 88 <br /> Native Hawaiian or other Pacific Islander 0 0 0 <br /> Other: specify 13 8 8 <br /> Total 114 94 99 <br /> Of the above, how many Hispanic/Latino 1 4 4 <br /> Of the above, how many non-Hispanic/Latino 113 <br /> 90 95 <br /> Total 114 94 99 .. <br /> ;Age <br /> 0-5 years 0 0 0 <br /> 6-18 years 0 0 0 <br /> 19-50 years 1 2 2 <br /> 51+ years 113 92 97 <br /> Total 114 94 99 ._ <br /> Geographic Location .. <br /> Alamance County 0 0 0 <br /> Chatham County 0 0 0 <br /> Durham County 0 0 0 <br /> Wake County 0 0 0 <br /> Orange County Breakdown <br /> Chapel I-lill Public Housing <br /> Town of Chapel Hill (Non-Public Housing) 27 40 42 <br /> Town of Carrboro 4 4 4 <br /> Tovvn of Hillsborough 39 38 40 <br /> ' City of Mebane (Orange County) 8 4 4 <br /> Orange County(Outside Municipalities) 36 8 8 <br /> Total 114 94 99 <br /> PROGRAM INFORMATION 1/23/2017 11:04:43 AM Page 13 of 17 <br />