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DocuSign Envelope ID: E7784BE7- 82AF- 4AF1- AA11- 944D2300E76D <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, Biracial, Arab, unspecified <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 />47 <br />55 <br />65 <br />27 <br />35 <br />45 <br />74 <br />90 <br />110 <br />14 <br />18 <br />25 <br />1 <br />1 <br />0 <br />0 <br />4 <br />5 <br />29 <br />37 <br />40 <br />0 <br />0 <br />0 <br />30 <br />30 <br />40 <br />74 <br />90 <br />110 <br />21 <br />27 <br />37 <br />53 <br />63 <br />73 <br />74 <br />90 <br />110 <br />74 <br />90 <br />110 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />74 <br />1 90 <br />110 <br />1 <br />1 <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 />5 <br />18 <br />25 <br />30 <br />8 <br />17 <br />20 <br />13 <br />14 <br />15 <br />6 <br />3 <br />6 <br />28 <br />30 <br />34 <br />Total 1 74 90 1 110 <br />PROGRAM INFORMATION 1/22/2018 3:23:54 PM Page 21 of 27 <br />