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DocuSign Envelope ID: E7F88FC1-7C61-4E68-8AF9-5870F711DEBC it A continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> Of the females, how many are single- <br /> female Head of Households(Omit for <br /> Human Services) <br /> Ethnicity <br /> African-American 35 40 45 <br /> American Indian or Alaska Native 0 0 0 <br /> Asian 3 3 5 <br /> Caucasian 190 214 215 <br /> Native Hawaiian or other Pacific <br /> Islander 0 0 0 <br /> Other 3 3 5 <br /> Totall 23 1 260 270 <br /> Of the above, how many <br /> Hispanic/Latino 0 0 0 <br /> Of the above, how many non- <br /> Hispanic/Latino <br /> Total 231 260 270 <br /> Age <br /> 0-5 years <br /> 6-18 years <br /> 19-50 years 12 20 10 <br /> 51-61 years 67 57 60 <br /> 62+years 152 183 200 <br /> Total 231 260 270 <br /> Geographic Location <br /> Durham City 83 90 90 <br /> Durham County 0 0 0 <br /> Carrboro 34 60 65 <br /> Chapel Hill 97 89 90 <br /> Chapel Hill Public Housing Residents ? ? ? <br /> Orange County 12 18 20 <br /> Raleigh 0 0 0 <br /> Wake County 5 3 5 <br /> 'fatal 231 260 270 <br /> Income Level—See following chart <br /> (Omit for HS) <br /> < 30%Area Median Income 200 230 240 <br /> 31-50%Area Median Income 31 30 30 <br /> 51-80%Area Median Income <br /> >80%Area Median Income <br /> Total 231 260 270 <br /> Special beads(Omit for HS) <br /> Elderly(Over 62) <br /> Disabled(not elderly) <br /> Homeless <br /> Main Application 1/25/201 6 1:23:46 PM Page 11 of 26 <br />