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Exhibit A- continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> Program/Proiect 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 Interest must be signed <br /> (m) Complete the Work Statement Chart to describe the work to be performed, and be sure <br /> to attach copies of all data collection tools that will be used to verify achievement of <br /> program 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: Community Education <br /> T-1111111 ­111111 _ fro ram,8�erii�fircia'``Qet�rtActual Estimated Projected <br /> 2014-15 2015-16 2016-17 <br /> Male N/A N/A N/A <br /> Female N/A N/A N/A <br /> Total N/A N/A N/A <br /> African-American N/A N/A N/A <br /> American Indian or Alaska Native N/A N/A N/A <br /> Asian N/A N/A N/A <br /> Caucasian N/A N/A N/A <br /> Native Hawaiian or other Pacific Islander N/A N/A N/A <br /> Other N/A N/A N/A <br /> Unknown N/A N/A N/A <br /> Total N/A N/A N/A <br /> Of the above, how many Hispanic/Latino N/A N/A N/A <br /> Of the above, how many non-Hispanic/Latino N/A NIA N/A <br /> Total N/A N/A N/A <br /> AR <br /> 0 <br /> 0-5 years 1,869 1,865 1,875 <br /> 6-18 years 10,523 10,600 10,650 <br /> 19-50 years 1,222 1,230 1,240 <br /> 51-61 years <br /> 62+years <br /> Unknown <br /> Total 13,614 13,695 13,765 <br /> Main Application 1/25/2016 12:55:42 PM P a g e 20 of 32 <br />