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DocuSign Envelope ID:71415AD7-DCDD-4CF6-89A9-F93F72D8DC62 XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <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 measures, <br /> and actual results. (Add more rows as needed) If this is a new program, you will only <br /> document the projected information. Every program is required to have AT LEAST 1 <br /> Program Activity, which should be SMART( pecific, Measurable, Achievable, Relevant, and <br /> Time-bound. Click on SMART Goals to learn more. <br /> O Program Activities should outline major activities the agency implements to accomplish its <br /> program goals. (i.e. Deliver meals to elderly/disabled residents) <br /> O Program Goal should explain what the program is trying to achieve/accomplish. Goals are <br /> statements about what the program should accomplish. (i.e. Deliver 100 meals per day, <br /> Monday-Friday.) <br /> O Performance Measures describe how you will evaluate the degree in which you achieved <br /> the stated goals. (i.e. Will track the number of meals delivered each day.) <br /> O Actual Program -esults use program results to indicate the actual measureable <br /> achievement of goals. If goals were not met, please explain. (i.e. Delivered an average of <br /> 105 meals per day.) <br /> Work Statement Chart for: Program Samaritan Relief Ministry <br /> 1. Program Activity Name Provide emergency groceries to food insecure households <br /> Program Goal Provide a week's worth of groceries to referred households a <br /> maximum of seven times in 12 months. <br /> Performance Measures Track the number of times individual households receive food <br /> through Access database. Produce monthly report of total number <br /> of individuals receiving assistance. <br /> Previous Year Program Results 9,478 individuals(-3,791 households) received food in 2016. <br /> Current Year Estimated Results 9,478 individuals(-3,791 households) will receive food in 2017 <br /> Next Year Projected Results 9,762 individuals(-3,905 households) will receive food in 2018 <br /> 2. Program Activity Name Provide emergency financial assistance for rent, utilities, and <br /> prescription medication. <br /> Program Goal 130 households will receive emergency financial assistance to be <br /> able to retain housing, utilities, or necessary medication. <br /> Performance Measures Track the amount of financial assistance individual households <br /> receive through Access database. Produce monthly report of total <br /> amount of financial assistance given. <br /> Previous Year Program Results 169 households received emergency financial assistance for rent <br /> and utilities in 2016. <br /> Current Year Estimated Results 169 households will receive emergency financial assistance for rent <br /> and utilities in 2017 <br /> Next Year Projected Results 174 households will receive emergency financial assistance for rent <br /> and utilities in 2018. <br /> 3. Program Activity Name <br /> Program Goal <br /> Performance easures <br /> Previous Year Program Results <br /> Current Year Estimated Results <br /> Next Year Projected Results <br /> PRir)P.PtiAn INMPA/14771-1A1 11'41/91117 R.41.9d AJtA P f Q <br />