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DocuSign Envelope ID: A0992361- 7662- 4FD7- 9DB3- 9D760E06A5D2 <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 <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 />87 <br />82 <br />87 <br />80 <br />98 <br />103 <br />167 <br />180 <br />190 <br />70 <br />78 <br />83 <br />0 <br />0 <br />0 <br />1 <br />2 <br />2 <br />94 <br />95 <br />99 <br />0 <br />0 <br />0 <br />2 <br />5 <br />6 <br />167 <br />180 <br />j 190 <br />2 <br />5 <br />6 <br />165 <br />177 <br />184 <br />167 <br />180 <br />190 <br />0 <br />0 <br />0 <br />26 <br />28 <br />30 <br />95 <br />102 <br />108 <br />47 <br />50 <br />52 <br />167 <br />180 <br />j 190 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />9 <br />10 <br />5 <br />0 <br />0 <br />0 <br />Total 1 167 180 1 190 <br />PROGRAM INFORMATION 1/22/2018 1:53:42 PM Page 15 of 18 <br />71 <br />77 <br />81 <br />12 <br />13 <br />15 <br />12 <br />13 <br />15 <br />23 <br />25 <br />27 <br />39 <br />42 <br />52 <br />Total 1 167 180 1 190 <br />PROGRAM INFORMATION 1/22/2018 1:53:42 PM Page 15 of 18 <br />