DHS90741 Forms 1 to 4.pdf

DHS Data Sheet

Legal Business Name (include d/b/a 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 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

Rev. 1/22/20

State of Utah, Department of Human Services (DHS)

SUBSTITUTE FORM W-9:

REQUEST FOR TAXPAYER IDENTIFICATION NUMBER & CERTIFICATION

TYPE OR PRINT INFORMATION NEATLY. PLEASE REFER TO INSTRUCTIONS FOR MORE INFORMATION.

Part I: Taxpayer Information

1. Full Legal Business Name: 2. Doing Business As (DBA) Name (if applicable):

3. Federal Tax Classification: (CHECK ONLY ONE BOX)

Partnership Governmental Entity LLC taxed as Corporation LLC taxed as Partnership

Individual/Sole Proprietor

LLC taxed as Sole Proprietor For-Profit Corporation Nonprofit Corporation Other (specify)_________________________________________________________________

4. Exemptions:

Exempt Payee Code (if any) ____________________

Exempt from FATCA reporting code (if any) ____________________

(Applies to accounts maintained outside the U.S.)

Part II: Taxpayer Identification Number (TIN) & Taxpayer Identification Type

1. Enter your TIN here: (DO NOT USE DASHES) See instructions.

2. Taxpayer Identification Type: (CHECK ONLY ONE BOX)

Employer ID No. (EIN) Social Security No. (SSN) Individual Taxpayer ID No. (ITIN)

Part III: Address

1. Legal Address:

Number, Street, and Apartment or Suite Number City, State, and Zip Code

Part IV: Certification (If this form is signed, the signature should be provided by the individual, owner, officer, legal representative, or other authorized person of the entity listed on the form.)

Under penalties of perjury, I certify that:

1. The number shown on this form is my correct Taxpayer Identification Number, and

2. I am a U.S. citizen or other U.S. person, and

3. I am not subject to backup withholding because: (a) I am exempt from back up withholding, (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and

4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certification Instructions. You must cross out item 3 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return.

A signature is required if you have been notified that you have previously given an incorrect TIN:

Signature of U.S. Person (if required) Title Date

Print Name Email Address Phone Number

DO NOT SUBMIT FORM TO IRS – SUBMIT FORM TO DHS ONLY AS DIRECTED

Rev. 11/19 State of Utah, Department of Human Services (DHS)

Instructions for Completing Substitute Form W-9

DHS must obtain the taxpayer’s full legal business name, federal tax classification and Taxpayer

Identification Number (TIN) to report income paid to it. DHS uses the Substitute Form W-9 to obtain certification of its TIN in order to ensure accuracy of information contained in its payee/vendor databases and to avoid backup withholding1. DHS asks for the information on the

Substitute Form W-9 to comply with Internal Revenue Service laws. Any payee/vendor who wishes to do business with DHS must complete the Substitute Form W-9. Payees/Vendors of

DHS are required to give DHS this information.

Part I: Taxpayer Information2

1. Full Legal Business Name:

a. Organizations: Enter the name shown on its charter or other legal documents creating the organization. Do not abbreviate the full legal business name or omit any portion of it, such as ending with “Inc.” or “LLC”.

b. Individuals: Enter the name of the person as it appears on the individual’s Social

Security card or other required federal tax documents.

2. Doing Business As (DBA) Name: Enter the DBA name or disregarded entity name.

3. Federal Tax Classification: Check the appropriate federal tax classification or check

“Other” and specify the appropriate federal tax classification not otherwise listed.

4. Exemptions: Refer to IRS Form W-9 instructions for an explanation of exemptions.

Part II: Taxpayer Identification Number (TIN) and Taxpayer Identification Type The TIN provided must match the name in the “Full Legal Business Name” box to avoid backup withholding. For individuals, this is your Social Security Number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, refer to IRS W-9 instructions for additional information. For other entities, it is your Employer Identification Number (EIN). If you do not have a number or if the account is in more than one name, refer to IRS W-9 instructions for additional information.

1. Taxpayer Identification Number (TIN): Enter taxpayer’s nine-digit Employer

Identification Number (EIN), Social Security Number (SSN), or Individual Taxpayer

Identification Number (ITIN).

2. Taxpayer Identification Type: Check the type of identification number provided.

Part III: Address

1. Provide full legal address.

Part IV: Certification A signature is required if you have been notified that you have previously given an incorrect

TIN. The name or signature, if required, should be provided by the individual, owner, officer, legal representative, or other authorized person of the entity listed on the form.

1 According to IRS Regulations, DHS must withhold 28% of all payments if a payee/vendor fails to provide DHS its certified TIN. The Substitute Form W-9 certifies a payee/vendor’s TIN.

2 A Utah-based payee/vendor that is required to register with the State of Utah, Department of Commerce

(Commerce) should ensure its full legal business name, federal tax classification, and any DBA provided match its registration with Commerce.

Conflict of Interest Disclosure Statement Page 1 of 1 Revised: 2/16/2018

State of Utah Department of Human Services Conflict of Interest Disclosure Statement

Instructions: Use a separate form for each employee with a conflict or potential conflict, and complete all applicable sections of the form. Typed responses are preferred.

Contractor/Vendor Legal Name:

Does an employee in your organization have a conflict of interest or potential conflict of interest? Yes ☐No ☐

☐ Dual Employment Name of person with dual employment:

Title or position with the State of Utah or political subdivision:

Title or position with the contractor/vendor:

Nature and value of the individual’s interest in contractor/vendor’s business:

Individual’s decision making authority with the contractor/vendor and with the State:

How does the vendor protect DHS from potentially adverse effects resulting from this individual’s conflict?

☐ Related-Party Transactions or Independent Judgment Impaired Name and position or title of individual associated with contractor/vendor:

Name and position or title of individual associated with other party:

Relationship between identified individuals:

Description of transaction involving identified individuals and dollar amount (if any):

Decision-making authority of individuals with respect to that transaction:

Potential effect on contract with DHS:

How does the contractor/vendor protect DHS from potentially adverse effects resulting from this identified conflict?

By submitting this form I certify that the information I have given is true and complete to the best of my knowledge.

Name and Title of Person Completing Form Date

For DHS Use Only

Approve ☐ Deny ☐ Reviewer Name and Division Date

“Approve” means the agency has no reason to question the accuracy of a “no conflicts” declaration or the agency has taken sufficient action to determine the facts declared by the contractor/vendor do not constitute a prohibited conflict of interest. DHS may refer questions regarding conflicts to the DHS Bureau of Internal Review and Audit (BIRA).

DHS90741

Form #4 - Service Selection Form

Personal Emergency Response Systems (PERS) Medical Dispensary Devices (MDD)

Instructions: Place an check in the “Check” column beside the service category(ies) the Vendor proposes to provide if awarded a contract pursuant to this solicitation.

SERVICE CATEGORY

SERVICE

CODE

PERS Home-Based Landline or Home-Based Cellular: WITH Fall Detection

This category includes the following services and billing codes:

PURCHASE of PERS Home-Based PEP

INSTALLATION of PERS PEI

REPLACEMENT of lost button/pendants for PERS Home-Based (landline & cellular) PEQ

MONITORING - LEASED PERS Home-Based with fall detection (landline & cellular) PEF

MONITORING - PURCHASED PERS Home-Based (landline & cellular; with & without fall detection)

PEO

MONITORING - Additional Persons through the same Home-Based transmission system

PES

PERS Home-Based Landline or Home-Based Cellular: WITHOUT Fall Detection

This category includes the following services and billing codes:

PURCHASE of PERS Home-Based PEP

INSTALLATION of PERS PEI

REPLACEMENT of lost button/pendants for PERS Home-Based (landline & cellular) PEQ

MONITORING - LEASED PERS Home Based - LANDLINE without fall detection PER

MONITORING - LEASED PERS Home Based – CELLULAR without fall detection PEC

MONITORING - PURCHASED PERS Home-Based (landline & cellular; with & without fall detection)

PEO

MONITORING - Additional Persons through the same Home-Based transmission system

PES

PERS Mobile Home & Away – Must Include Fall Detection

INSTALLATION of PERS PEI

REPLACEMENT of lost Mobile Home & Away PERS PMQ

MONITORING - LEASED PERS Mobile Home & Away - must include fall detection PEM

MDD

PURCHASE of MDD PE1

INSTALLATION of MDD PEI

MONITORING - LEASED MDD PE2

MONITORING – PURCHASED MDD PE4