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DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 <br />EXHIBIT A - 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 _Hispanic <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 />78 <br />82 <br />86 <br />31 <br />34 <br />37 <br />109 <br />116 <br />123 <br />18 <br />20 <br />22 <br />0 <br />0 <br />0 <br />1 <br />2 <br />2 <br />86 <br />88 <br />92 <br />0 <br />0 <br />0 <br />5 <br />6 <br />7 <br />109 <br />116 <br />123 <br />5 <br />6 <br />7 <br />104 <br />110 <br />116 <br />109 <br />116 <br />123 <br />0 <br />0 <br />0 <br />4 <br />4 <br />4 <br />55 <br />59 <br />63 <br />54 <br />57 <br />60 <br />109 <br />116 <br />F 123 <br />0 <br />0 <br />0 <br />4 <br />4 <br />4 <br />2 <br />2 <br />2 <br />0 <br />0 <br />0 <br />14 <br />14 <br />16 <br />37 <br />41 <br />44 <br />41 <br />44 <br />46 <br />10 <br />10 <br />10 <br />1 <br />1 <br />1 <br />0 <br />0 <br />0 <br />Total I 109 116 123 <br />PROGRAM INFORMATION 2/9/2017 1:51:06 PM P a g e 1 7 o f 2 6 <br />