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DocuSign Envelope ID: 717C8AE2- 4D6E- 4E46- A9A7- F4213973D039 <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 />I Program Target Population Demographics I <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 Middle Eastern <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 />79 <br />86 <br />94 <br />33 <br />39 <br />47 <br />112 <br />125 <br />141 <br />21 <br />30 <br />38 <br />0 <br />0 <br />0 <br />1 <br />2 <br />3 <br />89 <br />91 <br />97 <br />0 <br />0 <br />0 <br />1 <br />2 <br />3 <br />112 <br />125 <br />141 <br />6 <br />8 <br />10 <br />106 <br />117 <br />131 <br />112 <br />125 <br />141 <br />0 <br />0 <br />0 <br />0 <br />1 <br />1 <br />63 <br />68 <br />72 <br />49 <br />56 <br />68 <br />112 <br />1 125 <br />141 <br />0 <br />0 <br />0 <br />8 <br />10 <br />10 <br />3 <br />3 <br />3 <br />0 <br />0 <br />0 <br />14 <br />11 <br />15 <br />32 <br />29 <br />35 <br />43 <br />62 <br />67 <br />11 <br />8 <br />9 <br />1 <br />2 <br />2 <br />0 <br />0 <br />0 <br />Total 1 112 125 1 141 <br />PROGRAM INFORMATION 1/23/2018 1:58:29 PM Page 22 of 3 1 <br />