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DocuSign Envelope ID:990F6965-575D-4E0D-A54F-9DAD6D65198E t A - continued <br /> Provider's C tRic 38 Nlication <br /> Pro•ram/Pro'ect 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: Persons ❑Households ['Units <br /> Program: <br /> Program Beneficiary Demographics <br /> Actual Estimated Projected <br /> 2014-15 2015-16 2016-17 <br /> Gender _._._._....._..._..._........ <br /> Male 170 203 220 <br /> Female 345 412 447 <br /> Total 515 615 667 <br /> Of the females, how many are single- <br /> female Head of Households (Omit for <br /> Human Services) <br /> Ethnicity <br /> African-American 47 50 55 <br /> American Indian or Alaska Native 1 I 1 1 <br /> Asian 165 I 214 232 <br /> Caucasian 299 347 I 376 <br /> Native Hawaiian or other Pacific <br /> Islander I 0 0 I 0 <br /> Other I 3 3 rIIIIIIIIIIIIII <br /> Total IIIIIIIIIIIIMMI 615 667 <br /> Of the above, how many <br /> Hispanic/Latino 266 316 - 343 <br /> Of the above, how many non- <br /> Hispanic/Latino 249 299 324 <br /> Total 515 615 667 <br /> Age <br /> Y 0 <br /> 0-5 years �_.�_._...... _....... . _.._ <br /> 6-18 years 3 3 <br /> Main Application 1/26/2016 5:06:15 PM Page 9 of <br />