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DocuSign Envelope ID: DD554565-B9BA-4128-863D-805D6BC56619 i /\ - continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> Ethnicity <br /> African-American <br /> American Indian or A}aska Native <br /> Asian 981 991 1001 <br /> Caucasian <br /> Native Hawaiian or other Pacific <br /> Islander <br /> Other <br /> Total 981 j 981 / 1081 <br /> ' <br /> Of the above, how many <br /> ' � ' ' � � � � � <br /> Hispanic/Latino <br /> - <br /> Of the above, how many non- <br /> Hispanic/Lnbno <br /> Total 0 0 0 <br /> Age <br /> 0-5 years 98 100 102 <br /> 6-18 years 415 417 419 <br /> 19-50 years 361 363 365 <br /> 51-61 years 78 80 82 <br /> 62+ years 29 31 33 <br /> � � | <br /> Total 981 991 1001 <br /> Geographic Location <br /> Durham City <br /> Durham County <br /> | <br /> Canboro 384 387 390 <br /> Chapel Hill 529 534 539 <br /> Chapel Hill Public Housing Residents ? ? ? <br /> Orange County 68 70 72 <br /> Raleigh <br /> Wake County <br /> Total . 381 991 1,001 <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 <br /> Special Needs (Omit for HS) <br /> Elderly (Over 62) <br /> Disabled (not elderly) <br /> Homeless <br /> People with HIV/Aids <br /> � <br /> Total � 0 0 0 <br /> Main Application 1/25/2016 10:25:47 AM <br />