ExhibitCContractintakeform.doc

Contractor Intake

Instructions

All New DSHS Contractors must:

· Complete, sign and submit the Intake Form to the Department of Social and Health Services (DSHS).

· Register in the Statewide Payee Registration System. This system is maintained by the Washington State Office of Financial Management (OFM) to process payments for all Washington state agencies. To register, follow the online instructions at http://www.ofm.wa.gov/isd/vendors.asp. You must complete this step in order to be paid.

Please do not return this DSHS Contractor Intake Form to OFM; they will not process it.

All Existing DSHS Contractors who have changed their business name or business organization, or experienced other significant changes, must:

· Update their information in the Statewide Payee Registration System by following the instructions at http://www.ofm.wa.gov/isd/vendors.asp.

· Complete, sign and submit a new Contractor Intake form to the Department of Social and Health Services (DSHS).

Section One: Contractor Name/Business Organization

1.

Contractor name.

· For an Individual or Sole Proprietor, enter your name as shown on your Social Security card on the “Name” line. Sole Proprietors provide Last Name, First Name, Middle Name, and Suffix.

· Other entities. Enter your business name as shown on the legal document creating the entity.

2.

Business Organization. Please mark only one.

· If you are a nonresident alien foreign person or a business entity established in another state or country, the IRS may require you to complete Form W-8.

· If you are a Non-profit Corporation or a Faith-Based Non-Profit Corporation attach a copy of your 501(c) status.

3.

Taxpayer Identification Number (TIN).

· Individual or Sole Proprietor - If you are a sole proprietor you may enter either your Social Security Number (SSN), or if you have one, your federal Employer Identification Number (EIN).

· Other Business Entities - Enter the entity’s Employer Identification Number (EIN). If the entity does not have an EIN, enter the SSN of the owner of the business.

· Resident alien. - If you are a resident alien and you do not have and are not eligible to get an SSN, your TIN is your IRS individual taxpayer identification number (ITIN). Enter it in the SSN box.

4. Default Reported, Fiscal Year, UBI Number, and Business License

· List any contracts that you have had with the state that have been terminated for default.

· Provide your fiscal year end date.

· Provide your Washington State Uniform Business Identifier (UBI) Number.

· Attach a copy of your State Master Business License. You may be exempt from registering with the State of Washington under certain circumstances. For more information review: http://bls.dor.wa.gov/faqlicense.aspx

Section Two: Contractor Primary Address Enter the primary address information of your business. If you are completing this form for a new DSHS contract, and you want to provide a contract-specific address in addition to your primary one, please do so in Section Five.

Section Three: Contractor Ownership Check those that, in your opinion, apply to your organization. If you have a certification number, please provide that also. For the definition of microbusiness, minibusiness and small business, See RCW 39.26.010 (19), (20) and (21) Section Four: Contractor Contact Person(s) Enter the primary contact information, and job title, for your business. If you are completing this form for a new DSHS contract, and you want to provide a contract-specific contact person other than your primary one, please do so in Section Five.

Section Five: Additional Information 1.

Contractor Additional Addresses. If applicable, provide additional addresses used for DSHS Contracts.

2.

Contractor Additional Staff. If applicable, provide additional staff information for DSHS Contracts. Additional staff may include those who have authority to sign a DSHS contract on behalf of the business, and are referred to as a signatory.

Section Six: Contractor Certification You must sign, date, and return this form before DSHS will issue a contract.

Contractor Intake

Section One: Contractor Name/Business Organization (DSHS staff enter on ACD Intake Detail screen)

1.

CONTRACTOR NAME

DBA OR FACILITY NAME

2.

BUSINESS ORGANIZATION

FORMCHECKBOX

Individual or Sole Proprietor

FORMCHECKBOX

General Partnership

FORMCHECKBOX

Non-Profit Corporation (Attach a copy of 501(c) status)

FORMCHECKBOX

Limited Liability Partnership (LLP)

FORMCHECKBOX

For Profit Corporation

FORMCHECKBOX

Limited Liability Limited Partnership (LLLP)

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Faith Based (FBO) Non-Profit Corporation

FORMCHECKBOX

Limited Liability Company, filing as a Corporation

FORMCHECKBOX

Faith Based (FBO) Unincorporated

FORMCHECKBOX

Limited Liability Company, filing as a Partnership

FORMCHECKBOX

Governmental Entity

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Limited Liability Company, filing as a Sole Proprietor

FORMCHECKBOX

Foreign Person or Entity

If your business is NOT a sole proprietorship, attach a list of the partners, members, directors, officers, and board members.

3.

TAXPAYER IDENTIFICATION NUMBER (TIN)

Enter your TIN in the appropriate box.

· For individuals, this may be your Social Security Number (SSN).

· For other entities, it is your Employer Identification Number.

Social Security Number

OR

Employer Identification Number

(Enter all 9 numbers, NO DASHES)

(Enter all 9 numbers, NO DASHES)

4.

DEFAULT REPORTED, FISCAL YEAR, UBI NUMBER, AND BUSINESS LICENSE

Have you had any contract with the state terminated for default? FORMCHECKBOX Yes FORMCHECKBOX No

If yes, attach a list of terminated contracts with an explanation why each contract was terminated.

Is your fiscal year end the same as the calendar year (January 1 through December 31)? FORMCHECKBOX Yes FORMCHECKBOX No

If the answer is no, what is your fiscal year end date?

What is your Washington State Uniform Business Identifier (UBI) Number? (Enter all 9 numbers, NO DASHES) Attach a copy of your current Washington State Master Business License.

If you do not have a Washington State Master Business License, explain below why you are exempt from registering your business with the State of Washington. (See page 1 for information on exemptions.)

Section Two: Contractor Primary Address (DSHS staff enter on ACD Intake Detail screen)

CONTRACTOR PRIMARY ADDRESS (NUMBER, STREET, AND APARTMENT OR SUITE NUMBER)

CITY, STATE, AND ZIP CODE

EMAIL ADDRESS

COUNTY WHERE PRIMARY ADDRESS IS (FOR OUT-OF-STATE CONTRACTORS)

PHONE NUMBER (INCLUDE AREA CODE)

FAX NUMBER (INCLUDE AREA CODE)

Section Three: Contractor Ownership Type (DSHS staff enter, as applicable, on ACD Intake Detail screen)

In your opinion, do you consider your business to be one or more of the following? If so, please check the boxes that apply.

YES

NO

Disadvantaged Business Enterprise

FORMCHECKBOX

FORMCHECKBOX

Woman Owned Business Enterprise

FORMCHECKBOX

FORMCHECKBOX

Minority Owned Business Enterprise

FORMCHECKBOX

FORMCHECKBOX

Veteran Owned Business Enterprise

FORMCHECKBOX

Community Based Organization

FORMCHECKBOX

Microbusiness

FORMCHECKBOX

FORMCHECKBOX

Minibusiness

FORMCHECKBOX

FORMCHECKBOX

Small Business

FORMCHECKBOX

FORMCHECKBOX

If your business is Certified by Washington State’s Office of Minority and Women Owned Business Enterprises (OMWBE) http://www.omwbe.wa.gov, or Department of Veterans Affairs (DVA), enter the certification number.

Section Four: Contractor Primary Contact Person (DSHS staff enter on ACD Intake Detail screen)

Primary contact person is a(n):

FORMCHECKBOX

Owner

FORMCHECKBOX

Officer or Board Member FORMCHECKBOX Partner FORMCHECKBOX Staff Member FORMCHECKBOX Elected Official

FORMCHECKBOX

Other (please identify) (DSHS staff enter as applicable on ACD)

Is the primary contact person authorized to sign contracts?

FORMCHECKBOX

PRIMARY CONTACT NAME AND JOB TITLE

PHONE NUMBER (INCLUDE AREA CODE)

FAX NUMBER (INCLUDE AREA CODE)

PRIMARY CONTACT EMAIL ADDRESS

PAGER NUMBER (INCLUDE AREA CODE)

CELLULAR PHONE NUMBER (INCLUDE AREA CODE)

Section Five: Additional Information (DSHS staff enter on Intake Detail – Sub Information Summary screens)

1.

ADDITIONAL CONTRACTOR ADDRESSES:

IF YOU HAVE MORE THAN TWO ADDITIONAL ADDRESSES, YOU MAY ATTACH

A LISTING OF ADDITIONAL ADDRESSES.

FORMCHECKBOX

Billing address

FORMCHECKBOX

Facility address

Mailing address

CITY, STATE, AND ZIP CODE

PHONE NUMBER (INCLUDE AREA CODE)

COUNTY WHERE PRIMARY ADDRESS IS (FOR OUT-OF-STATE CONTRACTORS)

FAX NUMBER (INCLUDE AREA CODE)

EMAIL ADDRESS

FORMCHECKBOX

Billing address

FORMCHECKBOX

Facility address

Mailing address

CITY, STATE, AND ZIP CODE

PHONE NUMBER (INCLUDE AREA CODE)

COUNTY WHERE PRIMARY ADDRESS IS (FOR OUT-OF-STATE CONTRACTORS)

FAX NUMBER (INCLUDE AREA CODE)

EMAIL ADDRESS

2.

ADDITIONAL STAFF:

IF YOU HAVE MORE THAN TWO ADDITIONAL STAFF (LISTED BELOW), WHO ARE ALSO RELEVANT TO YOUR DSHS CONTRACTS, PLEASE PROVIDE INFORMATION ABOUT THOSE STAFF ON A SEPARATE PAGE.

Additional staff person is a(n):

Officer or Board Member FORMCHECKBOX Partner FORMCHECKBOX Staff Member FORMCHECKBOX Elected Official

Other (please identify) (DSHS staff enter as applicable on ACD)

Is the additional staff authorized to sign contracts?

FORMCHECKBOX

Yes FORMCHECKBOX No

Is the additional staff a contact for DSHS contracts?

FORMCHECKBOX

ADDITIONAL STAFF NAME

PHONE NUMBER (INCLUDE AREA CODE)

FAX NUMBER (INCLUDE AREA CODE)

ADDITIONAL STAFF EMAIL ADDRESS

PAGER NUMBER (INCLUDE AREA CODE)

CELLULAR PHONE NUMBER (INCLUDE AREA CODE)

Additional staff person is a(n):

Officer or Board Member FORMCHECKBOX Partner FORMCHECKBOX Staff Member FORMCHECKBOX Elected Official

Other (please identify) (DSHS staff enter as applicable on ACD)

Is the additional staff authorized to sign contracts?

FORMCHECKBOX

Yes FORMCHECKBOX No

Is the additional staff a contact for DSHS contracts?

FORMCHECKBOX

ADDITIONAL STAFF NAME

PHONE NUMBER (INCLUDE AREA CODE)

FAX NUMBER (INCLUDE AREA CODE)

ADDITIONAL STAFF EMAIL ADDRESS

PAGER NUMBER (INCLUDE AREA CODE)

CELLULAR PHONE NUMBER (INCLUDE AREA CODE)

Section Six: Contractor Certification (DSHS staff enter on ACD Intake Detail as Intake Form Date)

You must sign, date, and return this form.

I certify, under penalty of perjury as provided by the laws of the State of Washington, that all of the foregoing statements are true and correct, and that I will notify DSHS of any changes in any statement.

SIGNATURE

DATE

PRINTED NAME

TITLE

ATTACHED SUPPORTING DOCUMENTATION CHECKLIST

FORMCHECKBOX

Copy of your W-9 - Request or Taxpayer Identification Number and Certification

FORMCHECKBOX

Copy of statement showing non-profit 501(c) status (if applicable)

FORMCHECKBOX

List of partners, members, directors, officers, and board members (not applicable to sole proprietors)

FORMCHECKBOX

Copy of your Washington State Master Business License or proof of exemption

FORMCHECKBOX

List of any contracts you have had with the state that have been terminated for default, including a brief explanation (if applicable)

FORMCHECKBOX

List of Additional Addresses (if applicable)

FORMCHECKBOX

List of Additional Staff (if applicable)

Copy of your Certificate of Insurance (if applicable)

DSHS 27-043 (REV. 02/2013)