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DocuSign Envelope ID:40C90B7F-D85F-4E1C-A5CA-4BC263526A8E t A - continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> Of the females, how many are single- <br /> female Head of Households (Omit for <br /> Human Services) <br /> Ethnicity <br /> African-American 26 28 28 <br /> American Indian or Alaska Native <br /> Asian <br /> Caucasian 40 42 42 <br /> Native Hawaiian or other Pacific <br /> Islander <br /> Other <br /> Total 66 70 70 <br /> Of the above, how many <br /> Hispanic/Latino 0 <br /> Of the above, how many non- <br /> Hispanic/Latino 66 70 70 <br /> Total 66 70 70 <br /> Age <br /> 0-5 years <br /> 6-18 years <br /> 19-50 years 2 2 2 <br /> 51-61 years 6 7 7 <br /> 62+ years 58 61 61 <br /> Total 66 70 70 <br /> Geographic Location <br /> Durham City <br /> Durham County <br /> Carrboro <br /> Chapel Hill <br /> Chapel Hill Public Housing Residents <br /> Orange County 66 70 70 <br /> Raleigh <br /> Wake County <br /> Total 66 70 70 I <br /> Income Level —See following chart <br /> (Omit for HS) <br /> < 30%Area Median Income <br /> 31-50% Area Median Income <br /> 51-80% Area Median Income <br /> > 80%Area Median Income <br /> Total 0 0 0 <br /> Special Needs (Omit for HS) <br /> Elderly(Over 62) <br /> Disabled (not elderly) <br /> Homeless <br /> People with HIV/Aids <br /> Main Application 5/25/2016 9:29:51 AM P of 22 <br />