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DocuSign Envelope ID:6BDD2794-5ECO-4DFF-B4F6-F496A1C3AB13 t A - continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> Program/Project Information <br /> j) Complete the Target Population and Program Beneficiary Demographics Chart <br /> k) Complete the Schedule of Positions Chart for Program Staff <br /> I) 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: Community Engagement and Support <br /> Program Beneficiary Demographics <br /> Actual Estimated Projected <br /> 2014-15 2015-16 2016-17 <br /> Gender <br /> Male 60 12 60 <br /> Female 90 29 90 <br /> Total 150 41 150 <br /> Of the females, how many are single- <br /> female Head of Households (Omit for <br /> Human Services) <br /> Ethnicity <br /> African-American <br /> American Indian or Alaska Native <br /> Asian <br /> Caucasian <br /> Native Hawaiian or other Pacific <br /> Islander <br /> Other 150 41 150 <br /> Total 150 41 150 <br /> Of the above, how many <br /> Hispanic/Latino 130 34 130 <br /> Of the above, how many non- <br /> Hispanic/Latino 20 7 20 <br /> Total 150 41 150 <br /> Age <br /> 0-5 years 35 n/a <br /> 6-18 years 40 n/a <br /> Main Application 5/24/2016 4:41:23 PM P , 5 of <br />