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DocuSign Envelope ID: CC5DDEFF- F35B- 45F1- AD01- 4586504D8AF6 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />Additional Proqram 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 />Other <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 _Multi - racial_ <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 />Total <br />Actual Estimated Projected <br />2016 -17 2017 -18 1 2018 -19 <br />257 <br />336 <br />366 <br />318 <br />283 <br />308 <br />1 <br />1 <br />1 <br />590 <br />620 <br />675 <br />322 <br />367 <br />400 <br />13 <br />14 <br />15 <br />4 <br />0 <br />0 <br />182 <br />171 <br />186 <br />2 <br />3 <br />3 <br />67 <br />65 <br />71 <br />590 <br />620 <br />675 <br />570 <br />600 <br />653 <br />20 <br />20 <br />22 <br />590 <br />620 <br />675 <br />0 <br />0 <br />0 <br />0 <br />10 <br />12 <br />298 <br />302 <br />329 <br />292 <br />308 <br />334 <br />590 <br />620 <br />675 <br />10 <br />10 <br />12 <br />3 <br />3 <br />3 <br />38 <br />38 <br />40 <br />10 <br />9 <br />10 <br />24 <br />38 <br />42 <br />382 <br />380 <br />414 <br />96 <br />114 <br />124 <br />14 <br />14 <br />15 <br />3 <br />3 <br />3 <br />10 <br />11 <br />12 <br />590 <br />620 <br />675 <br />PROGRAM INFORMATION 1/22/2018 6:35:06 PM <br />Page 19 of 25 <br />