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DocuSign Envelope ID:A65EF081-BF54-47AC-9969-94226D3FBC7E t A - continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> Of the females, how many are single-female Head of <br /> Households (Omit for Human Services) 8 9 9 <br /> Ethnicity <br /> African-American 23 32 33 <br /> American Indian or Alaska Native 0 0 0 <br /> Asian 0 0 0 <br /> Caucasian 1 2 1 <br /> Native Hawaiian or other Pacific Islander 0 0 0 <br /> Other 0 2 2 <br /> Total 24 36 36 <br /> Of the above, how many Hispanic/Latino 0 0 0 <br /> Of the above, how many non-Hispanic/Latino 24 36 36 <br /> Total 24 36 36 <br /> Age <br /> 0-5 years 0 0 0 <br /> 6-18 years 2 1 1 <br /> 19-50 years 5 4 2 <br /> 51-61 years 2 2 2 <br /> 62+ years 15 29 31 <br /> Total 24 36 36 <br /> Geographic Location <br /> Durham City 0 0 0 <br /> Durham County 0 0 0 <br /> Carrboro 0 4 1 <br /> Chapel Hill 15 20 29 <br /> Chapel Hill Public Housing Residents 0 0 0 <br /> Orange County 9 12 6 <br /> Raleigh 0 0 0 <br /> Wake County 0 0 0 <br /> Total 24 36 36 <br /> Income Level —See following chart (Omit for HS) <br /> < 30% Area Median Income 5 18 10 <br /> 31-50%Area Median Income 11 10 14 <br /> 51-80%Area Median Income 8 8 12 <br /> > 80% Area Median Income 0 0 0 <br /> Total 24 36 36 <br /> Special Needs (Omit for HS) <br /> Elderly (Over 62) 15 17 20 <br /> Disabled (not elderly) 2 4 1 <br /> Homeless 0 0 0 <br /> People with HIV/Aids n/a n/a n/a <br /> Main Application 1/25/201 6 1 2:11 :11 PM I p (;, ,: a p II "I .7 <br />