Form A For-Profit.pdf
PDF 89 KB Posted
- Solicitation number
- 21260602151446
- Issued by
- Philadelphia County, Philadelphia City, Pennsylvania
About this file
This is a For-Profit Agency Information Submission Form for the Pennsylvania Department of Human Services (DHS), designed to collect essential contact and administrative information from for-profit contractors providing services to the state. The form requires submission of corporate identification details, including the exact legal entity name, federal and local tax identification numbers, and the Philadelphia Business Privilege License number. Key personnel contacts must be designated, including the Executive Director, Fiscal Director, Board President, and Diversity Spend Monitor, with their respective phone, fax, and email information. The form also requests specification of a separate invoice payment address if it differs from the corporate headquarters address. The submission is tied to quarterly reporting of DHS contract money received and requires certification that all submitted information is accurate at the time of signature.
Contractors are required to affirm the accuracy of all completed categories and commit to notifying their compliance manager immediately of any changes to contact information throughout the fiscal year. The form serves as an ongoing compliance mechanism for for-profit agencies contracted with DHS, establishing a baseline record of contractor information for encumbrance processing, payment distribution, and diversity spend monitoring purposes. This submission appears to be part of the broader contracting process for group home care services for dependent adolescents ages 13-21, as outlined in the related state contract opportunity.
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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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