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DocuSign Envelope ID: El 573D55-1 DC0 -4F4C- 9784- 749E3E95640B <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 />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 /Latino <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 />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 />201( 1 2017 -18 2018 -19 <br />100 <br />111 <br />127 <br />190 <br />210 <br />243 <br />290 <br />320 <br />370 <br />110 <br />120 <br />138 <br />283 <br />306 <br />353 <br />5 <br />8 <br />10 <br />168 <br />178 <br />205 <br />290 <br />320 <br />370 <br />7 <br />14 <br />17 <br />290 <br />320 <br />370 <br />7 <br />14 <br />17 <br />283 <br />306 <br />353 <br />290 <br />320 <br />370 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />7 <br />9 <br />11 <br />283 <br />311 <br />359 <br />290 <br />320 <br />370 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />18 <br />20 <br />24 <br />107 <br />117 <br />134 <br />92 <br />102 <br />117 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />73 <br />81 <br />95 <br />Note: We deliver to Trinity Court, South Estes <br />PROGRAM INFORMATION 1/22/2018 9:22:00 AM <br />Page 20 of 26 <br />