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DocuSign Envelope ID:99BDCA4A-2934-455A-8D45-0C865AD016D0 it A continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> yours. We deeply appreciate your continued support and look forward to working together <br /> for many years in the future. <br /> Program/Project Information <br /> i) Complete the Target Population and Program Beneficiary Demographics Chart <br /> j) Complete the Schedule of Positions Chart for Program Staff <br /> k) Disclosure of Potential Conflicts of Interested must be signed <br /> I) 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: <br /> Program Beneficiary Demographics <br /> Actual Estimated Projected <br /> 2014-15 2015-16 2016-17 <br /> Gender <br /> Male 578 554 580 <br /> Female 490 471 492 <br /> Total 1068 1030 1072 <br /> Of the females, how many are single- <br /> female Head of Households (Omit for <br /> Human Services) 42% 45% 47% <br /> Ethnicity <br /> African-American 480 468 492 <br /> American Indian or Alaska Native 5 3 4 <br /> Asian 17 15 12 <br /> Caucasian 337 325 338 <br /> Native Hawaiian or other Pacific <br /> Islander 0 0 0 <br /> Other 229 219 225 <br /> Total 1068 1030 1072 <br /> Of the above, how many <br /> Hispanic/Latino 80 85 92 <br /> Of the above, how many non- <br /> Hispanic/Latino 149 134 225 <br /> Total 229 219 225 <br /> Main Application 5/24/2016 8:51:19 AM Pag e 11 of 25 <br />