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DocuSign Envelope ID:AB039DC1-8309-4D41-B525-6E84F973FAA6 <br /> EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION CONTINUED <br /> MAIN APPLICATION <br /> Proorarn/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: 0 Persons i4 Households E Units <br /> Program: Parent Aide Services <br /> Program Beneficiary Demographics <br /> Actual Estimated I Projected <br /> 2014-15 2015-16 2016-17 <br /> Gender 7 families 8 families 18 families <br /> Male 13 14 28 <br /> Female 16 11 24 <br /> Total 29 25 52 <br /> Of the females, how many are single- <br /> female Head of Households(Omit for <br /> Human Services) <br /> Ethnicity <br /> African-American FT— 4 10 <br /> American Indian or Alaska Native 0 <br /> Asian 0 <br /> Caucasian 6 12 34 <br /> Native Hawaiian or other Pacific <br /> Islander 0 <br /> Other 21 9 8 <br /> Total 29 25 52 <br /> Of the above, how many <br /> Hispanic/Latino 19 9 8 <br /> Of the above, how many non- <br /> Hispanic/Latino 10 , 16 44 <br /> Total 29 25 52 <br /> Age <br /> 0-5 years 5 7 14 <br /> 6-18 years 13 8 18 <br /> 19-50 years 11 10 20 <br /> -- ----- <br /> Main Application 1/24/20164:55:46 PM Page 10 of 21 <br />