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<br />Exhibit D <br />Monitoring <br /> <br />p <br /> <br />f <br /> <br />s <br /> <br />(f <br /> <br />5/04) <br /> <br /> er ormance ummary arm rev. <br /> Sponsor Name, Address and Telephone Reporting Period <br /> Beginning: <br /> Ending: <br /> Current Period Year to Date <br />Total Number Served (Check One) <br /> 0 Persons 0 Households <br />Income Data Current Period Year to Date <br /> Number of Low Income <br /> Number of Very Low Income <br /> Number of Extremely Low Income <br /> Current Period Year to Date <br />Racial/Ethnicity Data (Head of Household Only) Hispanic Hispani <br /> Ethnicity Ethnici1 <br />11 White <br />12 Black/ African American <br />13 Asian <br />14 American Indian*/Alaskan Native <br />15 Native Hawaiian/Pacific Islander <br />16 American Indian*/Alaskan Native and White <br />17 Asian and White <br />18 Black/ African American and White <br />19 Amer. Ind.*/Alaskan. Native and Black/African <br /> Amer. <br />20 Other Multi-Racial <br />Other Demographics (Head of Household Only) Current Period Year to Date <br /> Female <br /> Elderly <br /> Handicapped <br /> <br />10: includes indigenous peoples from both North and South American continents <br />