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MAIN APPLICATION <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 />1) 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: ® Persons ❑ Households ❑ Units <br />Program: Client Services <br />Actual Estimated Projected <br />2014 -15 2015 -16 2016 -17 <br />Male <br />69 <br />66 <br />72 <br />Female <br />405 <br />410 <br />420 <br />Other <br />4 <br />6 <br />10 <br />Unknown* <br />46 <br />108 <br />98 <br />Total <br />524 <br />590 <br />600 <br />Of the females, how many are single - female N/A N/A N/A <br />Head of Households (Omit for Human Services) <br />iEthhicity <br />African - American <br />American Indian or Alaska Native <br />Asian <br />Caucasian <br />Native Hawaiian or other Pacific Islander <br />Other <br />Unknown* <br />Total <br />Of the above, how many Hispanic /Latino <br />Of the above, how many non - Hispanic /Latino <br />Total <br />26 <br />18 <br />30 <br />1 <br />1 <br />1 <br />10 <br />2 <br />4 <br />130 <br />174 <br />175 <br />0 <br />0 <br />0 <br />59 <br />108 <br />128 <br />298 <br />287 <br />262 <br />524 <br />590 <br />600 <br />52 <br />106 <br />126 <br />174 <br />197 <br />212 <br />524 <br />590 <br />600 <br />Main Application 1/25/2016 12:55:42 PM P a g e 1 0 o f 3 2 <br />