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DocuSign Envelope ID:8A1AB1 BF-ACDB-42A1-A3DE-9E9549E569B4 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> County) <br /> 2,292 .........�....... 2,407_...._...._............._2;610...... <br /> Of the above, how many Hispanic/Latino (29%) (29%) (29%) <br /> Of the above, how many non-Hispanic/Latino <br /> Total 7,900 8,300 9,000 <br /> Age <br /> 0-5 years 958 1006 1,089 <br /> 6-18 years 1561 1640 1,800 <br /> 19-50 years 3423 3596 3,870 <br /> 51+ years 1,198 1,260 2,241 <br /> Total 7,900 8,300 9,000 <br /> Geographic Location <br /> Alamance County '. ........__...X............................................X www _.�mw .��Xm_ �._ <br /> Chatham County X X x <br /> Durham County X X x <br /> Wake County X X x <br /> Orange County Breakdown <br /> Chapel Hill Public Housing X X x <br /> Town of Chapel Hill (Non-Public Housing) X X x <br /> Town of Carrboro X X..�..i._...___ x_..._._... <br /> Town of Hillsborough X L_......._.._........_. _.._...,.. ..._.......�.._._ ....._.__...X <br /> City of Mebane (Orange County) X X x <br /> Orange County (Outside Municipalities) I X X x <br /> p,, ,p ir Total <br /> l ° l � r ps <br /> rt on iiiuir t uu uu° s°tiiu���� . for pr re <br /> be m., .IIIl liii.liiisiiii°°ies i Illh Vii liii net dela Mat has Illh :,e nslllh s red % liiitim .. <br /> Work Statement <br /> m) Complete the Work Statement Chart to describe the work to be performed. <br /> This chart is used to document program activities, program goals, performance <br /> measures, and actual results. (Add more rows as needed) If this is a new program, <br /> you will only document the projected information. Every program is required to <br /> have AT LEAST 1 Program Activity, which should be SMART (Specific, <br /> Measurable, Achievable, Relevant, and Time-bound. Click on SMART G l to <br /> learn more. <br /> • Program Activities should outline major activities the agency implements to <br /> accomplish its program goals. (i.e. Deliver meals to elderly/disabled residents.) <br /> Page 15 of 20 <br />