Form A For-Profit.pdf
PDF 89 KB Posted
- Solicitation number
- 21260602084904
- Issued by
- Philadelphia County, Philadelphia City, Pennsylvania
About this file
This is a For-Profit Agency Information Submission Form required by the Office of Children and Family Services (OCF) and Department of Human Services (DHS) in Pennsylvania for organizations receiving DHS contract funding. The form serves as an official agency information registration document that must be completed and submitted by for-profit entities that have been awarded or are receiving DHS contracts. The form requires submission during specified fiscal year quarters and necessitates reporting of the exact amount of DHS contract money received during that quarter.
The form requires submission of comprehensive organizational and contact information, including the exact corporate name, federal identification number, city tax identification number, Philadelphia Business Privilege License number, and corporate address. Required personnel contacts include the Executive Director, Fiscal Director, and Board President, each with associated phone, fax, and email information. Additionally, organizations must designate a Diversity Spend Monitor Contact and provide an alternative invoice payment address if different from the corporate address. The form includes an affirmation statement whereby the Executive Director certifies that all information provided is accurate at the time of signature and commits to submitting updated information to the compliance manager immediately if any contact information changes during the fiscal year. This submission requirement ensures DHS maintains current organizational records for all for-profit vendors operating under active contracts.
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Text version
DATE OF SUBMISSION: CONTRACT #:
FISCAL YEAR: QUARTER:
AMOUNT OF DHS CONTRACT MONEY RECEIVED THIS QUARTER: $
EXACT CORPORATE NAME:
CORPORATE ADDRESS:
FEDERAL ID#:
CITY TAX ID#:
PHILA BUSINESS PRIVILEGE
LICENSE #:
EXECUTIVE DIRECTOR:
PHONE: FAX:
EMAIL:
FISCAL DIRECTOR:
PHONE: FAX:
EMAIL:
BOARD PRESIDENT:
PHONE: FAX:
EMAIL:
DIVERSITY SPEND
MONITOR CONTACT:
PHONE: FAX:
EMAIL:
Please indicate the exact address for invoice payments if different than the corporate address.
(This address will be used for encumbrance documents and payments. Please be specific.)
Signature of Executive Director: Date:
OCF/ DHS For-Profit Agency Information Submission Form
I affirm that the information provided is accurate for all categories completed on this form at the time of signature. If any contact information changes throughout the fiscal year, I will submit an updated version of this form to my comformance manager immediately.
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