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DocuSign Envelope ID: 1327919D -9891- 4603- B056- 5CA1EBBFDF23 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />Additional Program Information <br />nj 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 />Actual Estimated Projected <br />2016 -17 1 2017 -18 2018 -19 <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 <br />Total <br />50 <br />55 <br />55 <br />25 <br />30 <br />30 <br />75 <br />80 <br />80 <br />15 <br />15 <br />15 <br />44 <br />45 <br />45 <br />6 <br />5 <br />5 <br />43 <br />45 <br />45 <br />75 <br />j 80 <br />80 <br />17 <br />20 <br />20 <br />75 <br />80 <br />80 <br />Of the above, how many Hispanic /Latino 14 <br />Of the above, how many non-Hispanic/Latino <br />Total 0 0 19 <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 />25 <br />30 <br />30 <br />44 <br />45 <br />45 <br />6 <br />5 <br />5 <br />15 <br />20 <br />120 <br />75 <br />j 80 <br />80 <br />95 <br />45 <br />65 <br />0 <br />0 <br />0 <br />110 <br />20 <br />45 <br />15 <br />20 <br />120 <br />Orange County Breakdown <br />Chapel Hill Public Housing <br />Town of Chapel Hill (Non - Public Housing) <br />Town of Carrboro <br />PROGRAM INFORMATION 112212018 1:39 :57 PM Page 19 of 25 <br />