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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 />z) 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 />I Program Target Population Demographics j <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 <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 />AlamanceCounty <br />Chatham County <br />Durham County <br />Wake County <br />Orange County Breakdown <br />Chapel Hill Public Housing 50 60 <br />Town of Chapel Hill (Non - Public Housing) <br />Town of Carrboro 10 <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 />Total 1 0 50 1 70 <br />PROGRAM INFORMATION 1/31/2017 10:54:56 AM Page 21 of 26 <br />20 <br />25 <br />10 <br />30 <br />50 <br />35 <br />0 <br />20 <br />50 <br />30 <br />70 <br />Total 1 0 50 1 70 <br />PROGRAM INFORMATION 1/31/2017 10:54:56 AM Page 21 of 26 <br />25 <br />30 <br />10 <br />30 <br />50 <br />60 <br />0 <br />20 <br />50 <br />30 <br />70 <br />5 <br />10 <br />0 <br />50 <br />70 <br />Total 1 0 50 1 70 <br />PROGRAM INFORMATION 1/31/2017 10:54:56 AM Page 21 of 26 <br />20 <br />10 <br />10 <br />30 <br />50 <br />60 <br />0 <br />50 <br />70 <br />Total 1 0 50 1 70 <br />PROGRAM INFORMATION 1/31/2017 10:54:56 AM Page 21 of 26 <br />20 <br />15 <br />15 <br />10 <br />10 <br />50 <br />0 <br />50 <br />70 <br />Total 1 0 50 1 70 <br />PROGRAM INFORMATION 1/31/2017 10:54:56 AM Page 21 of 26 <br />