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DocuSign Envelope ID:78 e-B256-33o571Ae4687 [ /\- continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> Of the females, how many are single- <br /> female Head of Households (Omit for <br /> Human Services) <br /> Ethnicity <br /> African-American 6 8 11 <br /> American Indian or Alaska Native <br /> Asian <br /> Caucasian 72 79 84 <br /> Native Hawaiian or other Pacific |s|. <br /> Other 1 3 5 <br /> Total 79 90 100 <br /> Of the above how many <br /> Hispanic/Latino 1 2 3 <br /> Of the above how many non- <br /> Hispanic/Latino 78 88 97 <br /> � <br /> Total 79 � 80 100 <br /> Age <br /> 0-5 years <br /> 6-18 years 1111111111.11.=1 <br /> 19-50 years <br /> 51-61 years MIEIII=11M <br /> 62+ years 78 88 97 <br /> Total 79 90 100 <br /> Geographic Location <br /> Durham City <br /> Durham County 19 22 24 <br /> Carrboro 2 4 5 <br /> Chapel Hill 36 38 42 <br /> Chapel Hill Public Housing Residents <br /> Orange County 4 6 7 <br /> Raleigh <br /> Chatham/Alamance/Wake Counties 18 20 22 <br /> Total 79 80 100 <br /> Income Level—See following chart <br /> (Omit for HS) <br /> < 3OY6 Area Median Income <br /> 31-50%Area Median Income <br /> 51-8OY6 Area Median Income <br /> > 80%Area Median Income <br /> Total 0 0 0 <br /> Special Needs (Omit for HS) <br /> Elderly (Over 62) <br /> Disebled (not <br /> Homeless <br /> People with HIVfAids <br /> Total 0 0 0 <br /> Main Application 1/25/2016 11:54:37 AM Page 9 of 21 <br />