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DocuSign Envelope ID: E8DFACF7 -45BE- 435E- 9B5A- BB177E968F07 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />Additional Program Information <br />n) 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 />Gender <br />Program Target Population demographics I <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 />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 />2016 -17 2017 -18 2018 -19 <br />36 <br />38 <br />40 <br />61 <br />64 <br />67 <br />97 <br />102 <br />107 <br />2 <br />2 <br />2 <br />0 <br />0 <br />0 <br />3 <br />3 <br />3 <br />88 <br />92 <br />97 <br />0 <br />0 <br />0 <br />4 <br />4 <br />4 <br />97 <br />102 <br />107 <br />0 <br />2 <br />4 <br />97 <br />100 <br />103 <br />97 <br />102 <br />107 <br />0 <br />0 <br />0 <br />97 <br />0 <br />0 <br />1 <br />2 <br />4 <br />96 <br />100 <br />103 <br />97 <br />102 <br />107 <br />17 <br />18 <br />19 <br />13 <br />15 <br />17 <br />1,003 <br />1,053 <br />1,106 <br />132 <br />139 <br />43 <br />Total 1 97 102 1 107 <br />DO NOT SUBMIT THIS PAGE 1119/2018 12:42:41 PM Page 9 of 11 <br />38 <br />40 <br />42 <br />2 <br />2 <br />2 <br />39 <br />41 <br />43 <br />6 <br />6 <br />7 <br />12 <br />13 <br />13 <br />Total 1 97 102 1 107 <br />DO NOT SUBMIT THIS PAGE 1119/2018 12:42:41 PM Page 9 of 11 <br />