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Exhibit A- continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <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 /> 1) 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:Client Services <br /> Actual Estimated Projected <br /> 2014-15 2015-16 2016-17 <br /> .......... <br /> Male 69 66 72 <br /> Female 405 410 420 <br /> Other 4 6 10 <br /> Unknown* 46 108 98 <br /> Total 524 590 600 <br /> Of the females, how many are single-female N/A N/A N/A <br /> Head of Households Omit for Human Services <br /> M4 ■■yyam. Y <br /> African-American 26 18 30 <br /> American Indian or Alaska Native 1 1 1 <br /> Asian 10 2 4 <br /> Caucasian 130 174 175 <br /> Native Hawaiian or other Pacific Islander 0 0 0 <br /> Other 59 108 128 <br /> Unknown* 298 287 262 <br /> Total 524 590 600 <br /> Of the above, how many Hispanic/Latino 52 106 126 <br /> Of the above, how many non-Hispanic/Latino 174 197 212 <br /> Total 524 590 600 <br /> Main Application 1/25/2016 12:55:42 PM Page 10 of 3 2 <br />