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Page 19 of 23 <br />2016-17 2017-18 2018-19 <br />Gender <br />Male 7 7 7 <br />Female 24 23 23 <br />Total 31 30 30 <br />Ethnicity <br />African-American 24 26 26 <br />American Indian or Alaska Native 0 0 0 <br />Asian 2 2 2 <br />Caucasian 5 2 2 <br />Native Hawaiian or other Pacific Islander 0 0 0 <br />Other: specify __________________ 0 0 0 <br />Total 31 30 30 <br />Of the above, how many Hispanic/Latino 0 1 1 <br />Of the above, how many non-Hispanic/Latino 31 29 29 <br />Total 31 30 30 <br />Age <br />0-5 years 0 0 0 <br />6-18 years 0 0 0 <br />19-50 years 3 3 3 <br />51+ years 28 27 27 <br />Total 31 30 30 <br />Geographic Location <br />Alamance County 0 0 0 <br />Chatham County 0 0 0 <br />Durham County 0 0 0 <br />Wake County 0 0 0 <br />Orange County Breakdown <br />Chapel Hill Public Housing 0 0 0 <br />Town of Chapel Hill (Non-Public Housing) 24 11 11 <br />Town of Carrboro 2 3 3 <br />Town of Hillsborough 3 6 6 <br />City of Mebane (Orange County) 0 0 0 <br />Orange County (Outside Municipalities) 2 10 10 <br />Total 31 30 30 <br /> <br />Work Statement <br />o) Complete the Work Statement Chart to describe the work tobe performed. <br />This chart is used to document program activities, program goals, <br />performance measures, and actual results. (Add more rows as needed) If this <br />is a new program, you will only document the projected information. Every <br />program is required to have AT LEAST 1 Program Activity, which should be <br />SMART (Specific, Measurable, Achievable, Relevant, and Time-bound. Click <br />on SMART Goals to learn more. <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />DocuSign Envelope ID: 1263366F-0902-4D24-AE16-FC2EBB866669