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DocuSign Envelope ID: DBF0775B-3A75-4D97-9EA7-5AC7933304BF t A - continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> Of the above, how many non- <br /> Hispanic/Latino Unknown Unknown Unknown <br /> Total 0 0 0 <br /> Age-unavailable <br /> 0-5 years <br /> 6-18 years <br /> 19-50 years <br /> 51-61 years <br /> 62+years <br /> Total 0 0 0 <br /> Geographic Location—All events <br /> take place in and around <br /> Hillsborough, but participants for the <br /> events come from across Orange <br /> County, as well as the surrounding <br /> area. <br /> Durham City <br /> Durham County <br /> Carrboro <br /> Chapel Hill <br /> Chapel Hill Public Housing Residents <br /> Orange County <br /> Raleigh <br /> Wake County <br /> Total I 0 0 0 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 /> Total 0 0 0 <br /> Main Application 1/22/2016 8:56:04 AM Page 1111 of 2 <br />