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DocuSign Envelope ID: DDOCFB62- 8EDD- 4B57- ACF6- 9C98BO78AA95 XHIBIT A <br />PROVIDER'S OUTSIDE AGENCY APPLICATION <br />Additional Program Information <br />1) 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 />Gender <br />Male <br />Female <br />Total <br />Ethnicity <br />African - American <br />American Indian or Alaska Native <br />Asian <br />Caucasian <br />Native Hawaiian or other Pacific Islander <br />Other: specify _multi- cultural <br />Total <br />Of the above, how many Hispanic /Latino <br />Of the above, how many non - Hispanic /Latino <br />Total <br />Age <br />0 -5 years <br />6 -18 years <br />19 -50 years <br />51+ years <br />Total <br />Geographic Location <br />Alamance County <br />Chatham County <br />Durham County <br />Wake County <br />Orange County Breakdown <br />Chapel Hill Public Housing <br />Town of Chapel Hill (Non - Public Housing) <br />Town of Carrboro <br />Town of Hillsborough <br />City of Mebane (Orange County) <br />Orange County (Outside Municipalities) <br />Actual Estimated Projected <br />2015 -16 2016 -17 2017 -18 <br />202 <br />272 <br />225 <br />331 <br />381 <br />343 <br />533 <br />653 <br />568 <br />61 <br />70 <br />70 <br />274 <br />352 <br />324 <br />175 <br />253 <br />210 <br />296 <br />330 <br />288 <br />2 <br />20 <br />25 <br />1 <br />0 <br />0 <br />533 <br />653 <br />568 <br />259 <br />301 <br />244 <br />274 <br />352 <br />324 <br />533 <br />653 <br />568 <br />0 0 0 <br />5 8 10 <br />426 513 463 <br />102 132 95 <br />533 ' 653 568 <br />46 <br />35 <br />33 <br />5 <br />0 <br />5 <br />76 <br />75 <br />20 <br />6 <br />12 <br />6 <br />Total [ 528 653 1 568 <br />PROGRAM INFORMATION 1/31/2017 10:54:56 AM P a g e 13 of 2 6 <br />218 <br />240 <br />229 <br />93 <br />135 <br />110 <br />76 <br />125 <br />130 <br />2 <br />20 <br />25 <br />6 <br />11 <br />10 <br />Total [ 528 653 1 568 <br />PROGRAM INFORMATION 1/31/2017 10:54:56 AM P a g e 13 of 2 6 <br />