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DocuSign Envelope ID: 2AC82140-8F6C-4125-8743-OB8594E61466 <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 />Unknown <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: Multi- racial or Unknown <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 />Unknown <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 />2016 -17 2017 -18 2018 -19 <br />269 <br />299 <br />350 <br />249 <br />37 <br />280 <br />37 <br />330 <br />20 <br />555 <br />616 <br />700 <br />192 <br />203 <br />226 <br />0 <br />1 <br />7 <br />108 <br />130 <br />173 <br />174 <br />177 <br />196 <br />0 <br />3 <br />8 <br />81 <br />102 <br />90 <br />555 <br />616 <br />700 <br />132 <br />143 <br />155 <br />423 <br />473 <br />545 <br />555 <br />616 <br />700 <br />37 <br />42 <br />45 <br />483 <br />559 <br />640 <br />0 <br />0 <br />0 <br />0 <br />35 <br />0 <br />15 <br />0 <br />15 <br />555 <br />616 <br />700 <br />1 <br />0 <br />2 <br />0 <br />0 <br />2 <br />6 <br />3 <br />5 <br />1 <br />1 <br />2 <br />87 <br />83 <br />104 <br />258 <br />343 <br />365 <br />146 <br />172 <br />190 <br />1 <br />4 <br />10 <br />1 <br />2 <br />10 <br />0 <br />0 <br />10 <br />Unknown 54 8 <br />Total 1 555 616 700 <br />PROGRAM INFORMATION 1/23/2018 3:44:19 PM Page 15 of 21 <br />