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DocuSign Envelope ID: 3CD68914-055B-4274-9AF2-A50FD766FB76 t A - continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> Asian 8 8 8 <br /> Caucasian 117 120 130 <br /> Native Hawaiian or other Pacific <br /> Islander <br /> Other 3 3 3 <br /> Total 210 215 230 <br /> Of the above, how many <br /> Hispanic/Latino 47 49 54 <br /> Of the above, how many non- <br /> Hispanic/Latino 163 166 176 <br /> Total 210 215 230 <br /> Age <br /> 0-5 years <br /> 6-18 years 210 215 230 <br /> 19-50 years <br /> 51-61 years <br /> 62+ years <br /> Total 210 215 230 <br /> Geographic Location <br /> Durham City <br /> Durham County 6 6 6 <br /> Carrboro 20 21 24 <br /> Chapel Hill 108 110 117 <br /> Chapel Hill Public Housing Residents <br /> Orange County 76 78 83 <br /> Raleigh <br /> Wake County <br /> Total 210 215 230 <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 5/25/2016 10:34:40 AM P 12 of 25 <br />