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DocuSign Envelope ID:A3E0213B-1DCD-43A3-9C41-A2EC55A8CA94 t A - continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> other areas to pick up the balance. <br /> i) Include any other pertinent information. <br /> The program demographics show duplicated numbers. Each time a household is <br /> assisted, it draws from the programs resources and each time is considered a <br /> separate "crisis" for the household. Some households may only need help once, <br /> while others need help the maximum number of times. <br /> For the demographic information; Gender is only collected for adults, for <br /> informational purposes, the children were divided 50% female and 50% male. <br /> Ethnicity is collected by household, not individuals (the chart will reflect that), <br /> likewise, we collect age group information a little bit differently (the chart will reflect <br /> that.) <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 X Households ❑ Units <br /> Program: Samaritan Relief Ministry <br /> Program Beneficiary Demographics <br /> Actual Estimated Projected <br /> 2015 2016 2017 <br /> 2014-15 2015-16 2016-17 <br /> Gender <br /> Male 4799 5075 5075 <br /> Female 5976 6203 6203 <br /> Total 10,775 11,278 11,278 <br /> Of the females, how many are single- <br /> female Head of Households (Omit for <br /> Human Services) <br /> Ethnicity by Household <br /> African-American 1613 1687 1687 <br /> American Indian or Alaska Native <br /> Asian <br /> Caucasian 2094 2181 2181 <br /> Native Hawaiian or other Pacific <br /> Islander <br /> Other 223 247 247 <br /> Main Application 5/25/2016 9:39:17 AM P of 22 <br />