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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: Self- Sufficiency Programs <br />Gender <br />Male <br />Female <br />Unknown <br />Total <br />iry Demographics <br />Actual Estimated Projected <br />2014 -15 1 2015 -16 2016 -17 <br />176 <br />175 <br />30 <br />603 <br />645 <br />_175 <br />645 <br />32 <br />30 <br />30 <br />811 <br />850 <br />850 <br />Of the females, how many are single - <br />female Head of Households (Omit for <br />Human Services) <br />Ethnicity <br />African - American <br />American Indian or Alaska Native <br />30 <br />30 <br />806 <br />820 <br />100 <br />140 <br />140 <br />2 <br />2 <br />2 <br />Asian <br />Caucasian <br />Native Hawaiian or other Pacific <br />Islander <br />Other <br />Unknown <br />Total <br />Of the above, how many <br />Hispanic /Latino <br />Of the above, how many non- <br />Hispanic/Latino <br />Total <br />Age <br />5 <br />30 <br />30 <br />806 <br />820 <br />820 <br />21 <br />25 <br />25 <br />313 <br />315 <br />315 <br />0 <br />0 <br />0 <br />23 <br />25 <br />25 <br />352 <br />1 343 <br />1 343 <br />811 <br />1 850 <br />1 850 <br />5 <br />30 <br />30 <br />806 <br />820 <br />820 <br />811 <br />850 <br />850 <br />Main Application 1/24/2016 2:59:42 PM Page 24 of 58 <br />