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<br />Program information P a g e 18 o f 32 <br />American Indian or Alaska Native <br />Asian Indian <br />White <br />Native Hawaiian or Other Pacific Islander <br />Chinese <br />Japanese <br />Vietnamese <br />Filipino <br />Korean <br /> Some other race 50 50 <br />Total n/a n/a 50 0 <br /> <br />Of the above, how many Hispanic, Latino or Spanish origin 0 0 <br />Of the above, how many non-Hispanic, Latino or Spanish origin 50 50 <br />Total n/a n/a 50 0 <br />Age <br />0-5 years 10 12 <br />6-18 years 40 38 <br />19-50 years <br />51+ years <br />Total n/a n/a 50 50 <br />Geographic Location <br />Town of Chapel Hill 44 30 <br />Town of Carrboro 5 4 <br />Orange County (Outside of Chapel Hill/Carrboro) 0 8 <br />Outside of Orange County 1 8 <br />Total n/a n/a 50 50 <br />Income <br />Low-income (80% of the Area Median Income and Below) <br />Please see income table in the attachments 100% 100% <br />Total n/a n/a 50 50 <br /> <br /> <br /> <br />12. Cost Per Individual <br /> <br />This cost per individual must reflect the total program budget divided by the total number of program <br />individuals in this application. <br /> <br /> Actual 2021-2022 Projected 2022-2023 Projected 2023-2024 <br />Total Cost of Program n/a $62,755 $148,081 <br />Total # of Individuals n/a 50 50 <br />Cost Per Individual n/a $1255 $2961 <br /> <br />13. Performance Indicators <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATIONDocuSign Envelope ID: D2C31311-1A1A-4A30-9007-2F17D64E6227