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DocuSign Envelope ID: D9639255-8147-4A2F-A760-941BDE078E48 t A - continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> Of the above, how many <br /> Hispanic/Latino 3 8 8 <br /> Of the above, how many non- <br /> Hispanic/Latino 10 15 15 <br /> Total 13 23 23 <br /> Age <br /> 0-5 years <br /> 6-18 years 13 23 23 <br /> 19-50 years <br /> 51-61 years <br /> 62+ years <br /> Total 13 23 23 <br /> Geographic Location <br /> Durham City <br /> Durham County <br /> Carrboro <br /> Chapel Hill 13 23 23 <br /> Chapel Hill Public Housing Residents <br /> Orange County <br /> Raleigh <br /> Wake County <br /> Total 0 0 0 <br /> Income Level —See following chart <br /> (Omit for HS) <br /> < 30%Area Median Income <br /> 31-50% Area Median Income 11 22 22 <br /> 51-80% Area Median Income <br /> > 80%Area Median Income 2 1 1 <br /> Total 12 23 23 <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 10:17:47 AM .. of 2 <br />