6-26053 Form 1 Data Sheet.pdf
PDF 89 KB Posted
- Solicitation number
- DHHS26053
- Issued by
- Utah
About this file
This is a Form 1 Data Sheet for the Utah Department of Health and Human Services, Division of Services for People with Disabilities (DHHS) contract opportunity 6-26053 for Peer Support Services for Persons on the DSPD Wait List. The contract seeks to provide time-limited peer support services to individuals and their families who are waiting for Home and Community Based Services (HCBS), with the goal of helping them remain in home and community-based settings. Peer support services will be delivered by individuals with lived experience who will help identify needs, provide support and guidance, navigate systems, and connect persons and families to available resources.
The Form 1 Data Sheet serves as a vendor registration document requiring submission of standard business information including legal business name, business address, mailing address, contact information, and certification regarding tax liens in the State of Utah. The form requests the name and contact details of the person completing the form and requires certification that all information provided is true and complete to the best of the respondent's knowledge.
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Other files
| File | Type | Posted |
|---|---|---|
| 8-26053 Form 3 Conflict of Interest Disclosure Statement.pdf | ||
| 12-26053 DHHS Client Service Terms.docx | DOCX document | |
| 11-26053 Form 6 Technical Proposal.docx | DOCX document | |
| 4-26053 Document Submission Checklist.xlsx | XLSX spreadsheet | |
| 7-26053 Form 2 W-9.pdf | ||
| 9-26053 Form 4 Business Associate Agreement.pdf | ||
| 5-26053 Score Sheet.xlsx | XLSX spreadsheet | |
| 2-26053 Scope of Work.docx | DOCX document | |
| 1-26053 RFP.docx | DOCX document | |
| 3-26053 Rate Table.docx | DOCX document | |
| 10-26053 Form 5 Region Selection.docx | DOCX document |
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Text version
Form 1: Data Sheet
DHHS26053
Legal Business Name (include DBA if applicable)
Legal Business Address City State Zip Code
Business Mailing Address City State Zip Code
Business Email address Business Phone # (include area code)
Does the vendor have an outstanding tax lien in the State of Utah? Yes No
Contact Person and Title
Contact Person’s Email Address Contact Person’s Telephone # (include area code)
By submitting this form, I certify that the information I have given is true and complete to the best of my knowledge.
Name of Person Completing Form Date
Position or Title
File details come from the government source that posted it. Updated .