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DocuSign Envelope ID: EB294A71-C7D1-4EE4-8287-60A6149320D4 <br /> Work Statement <br /> o) 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 /> • Program Activities should outline major activities the agency implements to accomplish its <br /> program goals. (i.e. Deliver meals to elderly/disabled residents.) <br /> • 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 1001 meals per day, <br /> Monday-Friday.) <br /> • 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 /> • Actual Program Results 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 <br /> Homelessness Prevention and Emergency Assistance Program: Rent and Utility Assistance, Basic <br /> Needs Services <br /> 1. Program Activity Name Homelessness Prevention and Emergency Assistance: Rent <br /> and Utility Assistance <br /> Program Goal Prevent eviction or disconnection of utility services for <br /> member households <br /> Performance Measures Track the number of fulfilled requests for assistance <br /> Previous Year Program Results 477 fulfilled requests <br /> Current Year Estimated Results 550 fulfilled requests <br /> Next Year Projected Results 550 fulfilled requests <br /> 2. Program Activity Name Homelessness Prevention and Emergency Assistance: 'Basic <br /> Needs Services <br /> Program Goal Support member'households with basic unmet needs <br /> Performance Measures Track the number of fulfilled requests for assistance <br /> Previous Year Program Results 1,052 fulfilled requests.._. <br /> Current Year Estimated Results 950 fulfilled requests <br /> Next Year Projected Results 1 950 fulfilled re uests <br /> py Program Budget <br /> 1. Submit your program budget. You may complete the provided template (separate x1s <br /> file) or you may submit your own budget file (as long as it contains the same information, <br /> in the same format, as requested in the provided template). Attached <br /> Program Budgets are required to define budget amounts for the previous program <br /> year, current program year, and next program year for the following categories: <br /> • Revenues <br /> o Private Donations <br /> Agency Information 1123]2018 2:06:13 PM P a g e 1 3 o f 3 7 <br />