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DocuSign Envelope ID:4FFDF545 e8C1-4Aer~^0A5-400050A30357 i A - continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> 0 Quarterly Caregiver Newsletters for the families that we serve and prospective families. <br /> Program/Project Information <br /> C. Complete the Target Population and Program Beneficiary Demographics Chart <br /> D. Complete the Schedule of Positions Chart for Program Staff <br /> E. Disclosure of Potential Conflicts of Interested must be signed <br /> F. Complete the Work Statement Chart to describe the work to be performed, and be sure to <br /> attach copies of all data collection tools that will be used to verify achievement of program <br /> goals and objectives. Describe who will be responsible for monitoring progress. <br /> Information to Complete <br /> j.) Target Population <br /> Complete the following tables to the best of your ability. Show numbers of participants and <br /> percentages, as applicable, in each category. <br /> Please indicate whether this project/program will serve: X Persons 111 Households - Units <br /> Program: <br /> Program Beneficiary Demographics <br /> Actual Estimated Projected <br /> 2014'15 201546 2016-17 <br /> Gender <br /> Male 46 48 50 <br /> Female 36 38 42 <br /> Total 82 86 92 <br /> Of the fema|eo, how many are single- <br /> female Head of Households (Omit for <br /> Human Services) n/a n/a n/a <br /> Ethnicity <br /> African-American 24 25 30 <br /> American Indian or Alaska Native 2 1 3 <br /> Asian 2 4 5 <br /> Caucasian 54 54 50 <br /> Native Hawaiian or other Pacific <br /> Islander 0 0 1 <br /> Other 0 2 3 <br /> Total 82 88 92 <br /> Of the above, how many <br /> Hispanic/Latino 0 2 3 <br /> Of the above, how many non- <br /> H|opanio/LaUno 82 84 89 <br /> Total 82 86 92 <br /> Agm'` ��'` ``'^ ` <br /> 0-5 years <br /> 6-18 years <br /> Main Application 1/25/2016 12:26:51 PM Page 1 1 of 2 1 <br />