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Exhibit A- continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> with these programs if funding is not awarded or if reduced. <br /> i) Include any other pertinent information. <br /> Program/Proiect Information <br /> j) Complete the Target Population and Program Beneficiary Demographics Chart <br /> k) Complete the Schedule of Positions Chart for Program Staff <br /> 1) Disclosure of Potential Conflicts of Interested must be signed <br /> m) 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 ❑ Households ❑ Units <br /> Program: <br /> Program Beneficiary Demographics <br /> Actual Estimated Projected <br /> 2014-15 2015-16 2016-17 <br /> Gentler Transgender 1 1 1 <br /> Male 153 193 222 <br /> Female 85 110 126 <br /> Total 239 304 349 <br /> Of the females, how many are single- <br /> female Head of Households (Omit for <br /> Human Services) <br /> Ethnicity <br /> African-American 34 45 52 <br /> American Indian or Alaska Native <br /> Asian 13 15 <br /> Caucasian 158 178 205 <br /> Native Hawaiian or other Pacific <br /> Islander <br /> Other 47 68 78 <br /> Total 239 304 349 <br /> Of the above, how many <br /> Hispanic/Latino 9 9 10 <br /> Of the above, how many non- <br /> Hispanic/Latino 230 295 339 <br /> Total 1 239 1 304 1 349 <br /> Age <br /> Main Application 5/25/2016 10:10:25 AM P a g e 1 1 of 24 <br />