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DocuSign Envelope ID: 07FEE1A8- E83F- 44CF- 99C4- 61A6E4C39BD2 <br />EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION <br />Additional Program Information <br />a) 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 />*City /State /County <br />Disabled <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 />Geographic Location <br />0 -5 years <br />6 -18 years <br />19 -50 years <br />51+ years <br />Total <br />Actual Estimated Projected <br />2015 -16 2016 -17 2017 -18 <br />180 <br />180 <br />200 <br />335 <br />335 <br />350 <br />515 <br />515 <br />550 <br />300 <br />300 <br />325 <br />495 <br />495 <br />540 <br />500 <br />500 <br />560 <br />195 <br />195 <br />215 <br />500 <br />500 <br />530 <br />0 <br />0 <br />0 <br />5 <br />5 <br />20 <br />495 <br />495 <br />540 <br />500 <br />500 <br />560 <br />Alamance County <br />Chatham County <br />Durham County <br />Wake County <br />Orange County Breakdown 250 250 350 <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 />150 <br />150 <br />200 <br />50 <br />50 <br />55 <br />325 <br />325 <br />350 <br />125 <br />125 <br />130 <br />500 <br />500 <br />530 <br />Alamance County <br />Chatham County <br />Durham County <br />Wake County <br />Orange County Breakdown 250 250 350 <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 />150 <br />150 <br />200 <br />50 <br />50 <br />75 <br />50 <br />50 <br />75 <br />PROGRAM INFORMATION 2/9/2017 4:31:06 PM Page 17 of 22 <br />