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DocuSign Envelope ID:82431AC9-7F03-4084-815E-A2EFB34C92BB t A - continued <br /> Provider's RxiNcA4comdit9Rilication <br /> I) Include any other pertinent information, <br /> Program/Project Information <br /> j) Complete the Target Population and Program Beneficiary Demographics Chart <br /> k) Complete the Schedule of Positions Chart for Program Staff <br /> I) Disclosure of Potential Conflicts of Interested must be signed <br /> m) 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: X Persons X Households El Units <br /> Program: Community House, Home Start <br /> Program Beneficiary Demographics <br /> Actual Estimated Projected <br /> 2014-15 2015-16 2016-17 <br /> Gender <br /> Male 346 132 130 <br /> Female 149 176 170 <br /> Total 495 308 300 <br /> Of the females, how many are single- 129 176 170 <br /> female Head of Households(Omit for <br /> Human Services) <br /> Ethnicity <br /> African-American 302 144 141 <br /> American Indian or Alaska Native <br /> Asian <br /> Caucasian 149 152 147 <br /> Native Hawaiian or other Pacific <br /> Islander <br /> Other 44 12 12 <br /> Total 495 308 300 <br /> Of the above, how many 30 0 10 <br /> Hispanic/Latino <br /> Of the above, how many non- 465 308 290 <br /> Hispanic/Latino <br /> Total 495 308 300 <br /> Age <br /> 0-5 years 40 39 <br /> 6-18 years 28 27 <br /> Main Application 1/2512016 12:58:53 PM Page 12 of 33 <br />