Appendix A - Application Cover Sheet Checklist.pdf
PDF 294 KB Posted
- Attached to
- Family Support Programs
- Solicitation number
- 25-RFA-13800
- Issued by
- Pennsylvania
About this file
This document is an Application Cover Sheet and Checklist issued by the Commonwealth of Pennsylvania Department of Human Services for a Request for Applications (RFA 25-RFA-13800) seeking qualified applicants to implement Evidence Based Home Visiting (EBHV) programs designed to improve family health, increase school readiness, enhance economic well-being, prevent child abuse and neglect, and promote positive parenting. The Department's Office of Child Development and Early Learning (OCDEL) seeks to maintain at least one Family Support Program in each of Pennsylvania's 67 counties through community-based, high-quality EBHV services. Applicants must submit a complete technical submittal addressing all required sections, including organizational information, service capacity details, and model implementation plans, along with all mandated appendices and supporting documentation as specified in the RFA.
The application submission process requires completion and return of multiple required forms including cost worksheets, certifications related to lobbying and federal funding transparency, worker protection documentation, and organizational charts. Applicants for-profit organizations, not-for-profit entities, or local government agencies must provide their federal identification numbers, SAP/SRM vendor numbers, and unique entity identifiers. Applications must identify the specific EBHV model(s) being proposed, the county or counties where services will be provided, and any service area zip codes within Philadelphia County. Applicants requesting enhancements or proposing initial contract terms totaling $5.0 million or more must include additional specialized submittals such as the Contractor Partnership Program documentation. Failure to complete, sign, and submit all required forms and documentation may result in automatic rejection of the application.
View the file
Other files
Show all 21
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Appendix A Application Cover Sheet & Checklist
APPENDIX A
APPLICATION COVER SHEET & CHECKLIST
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF HUMAN SERVICES
25-RFA-13800
Applicant Information:
Applicant Name Applicant Mailing Address
Applicant Website Applicant Contact Person Contact Person’s Phone Number Contact Person’s Facsimile Number Contact Person’s E-mail Address
Organization Type □ For Profit □ Not-For-Profit □ Local Government Applicant Federal ID Number Applicant SAP/SRM Vendor Number Applicant Unique Entity Identifier
EBHV Model and Program Service County Name of EBHV Model(s) applying for:
County where EBHV Service will be provided:
Zip Code(s) if providing EBHV Services in Philadelphia County:
Signature Signature of an official authorized to bind the Applicant to the provisions contained in the Applicant’s application:
Printed Name
Title
FAILURE TO COMPLETE, SIGN AND RETURN THIS FORM WITH THE APPLICANT’S APPLICATION
MAY RESULT IN THE REJECTION OF THE APPLICANT’S APPLICATION.
CHECKLIST
You must complete, sign (if applicable) and submit the following documents as specified within this RFA.
____ Technical Submittal Part III. Provide responses to all sections.
____ Appendix B – Trade Secret Confidential Proprietary Information Notice.
____ Appendix C – Cost Submittal Worksheet. Review requirements, and complete and submit
____ Appendix D – Lobbying Certification and if applicable, the Disclosure of Lobbying Activities.
____ Appendix E – Federal Funding Accountability and Transparency Act Sub-Recipient Data Sheet.
____ Appendix F - Worker Protection and Investment Certification Form.
____ Appendix I - Program Requirements and Organization Information. Must include your Organizational Chart.
____ Appendix J – Service Capacity Worksheet & Model Implementation Approval. Include the requested attachment.
INCLUDE THESE ADDITIONAL DOCUMENTS ONLY IF APPLICABLE:
____ Appendix P – Enhancements Worksheet. Complete and include this form if requesting to implement an enhancement.
____ Part V –The Contractor Partnership Program (“CPP”) Submittal. Include a CPP Submittal if total cost for the initial term is $5.0 million or more.
Permissible Attachments: In addition to the documents listed above, only attachments detailed in the RFA are permitted to be included with this application.
File details come from the government source that posted it. Updated .