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DocuSign Envelope ID: D2CB2439-4B3B-42E7-A090-286FDDD6E948 t A - continued <br /> Provider's Outside Agency Application <br /> African-American 0 0 0 <br /> American Indian or Alaska Native <br /> Asian 3 4 5 <br /> Caucasian 0 0 0 <br /> Native Hawaiian or other Pacific Islander <br /> Other 5 6 7 <br /> Total 8 10 12 <br /> Of the above, how many Hispanic/Latino 2 3 3 <br /> Of the above, how many <br /> non-Hispanic/Latino 0 0 0 <br /> Total 8 10 12 <br /> Age <br /> 0-5 years 0 0 0 <br /> 6-18 years 2 2 3 <br /> 19-50 years 6 8 9 <br /> 51-61 years 0 0 <br /> 62+years <br /> Total 8 10 12 <br /> Geographic Location <br /> Durham City 0 0 0 <br /> Durham County 0 0 0 <br /> Carrboro 5 6 7 <br /> Chapel Hill 3 4 5 <br /> Chapel Hill Public Housing Residents <br /> Orange County <br /> Raleigh <br /> Wake County <br /> Total 8 10 12 <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 <br /> Special Needs (Omit for HS) <br /> Elderly(Over 62) <br /> Disabled (not elderly) <br /> Homeless <br /> People with HIV/Aids <br /> Total <br /> CDBG & HOME ONLY- Area Benefit Activities (Infrastructure and Public Facilities) <br />