4-DHHS26105 Form 1 - DHHS Data Sheet.pdf

This is a DHHS Data Sheet form for the Utah Department of Health and Human Services ("DHHS") related to a Residential Treatment Services contract opportunity. The form is designed to collect vendor information and business details from organizations interested in providing residential treatment programs for persons with serious emotional or behavioral disorders or disturbances. The document requests standard business registration information including legal business name, business addresses for both legal and mailing purposes, contact information, business email, and telephone numbers. Additionally, the form inquires whether the vendor has any outstanding tax liens in the State of Utah, which serves as a compliance screening mechanism.

The form requires completion and certification by an individual with signatory authority for the business, who must attest to the accuracy and completeness of the information provided. The document functions as an initial eligibility and registration form for vendors seeking to participate in the residential treatment services procurement process with the State of Utah. No specific pricing terms, award dates, contract terms, or renewal options are detailed within this data sheet, as it serves primarily as a vendor qualification and information-gathering instrument rather than a detailed scope of work or contract specification document.