Form A For-Profit.pdf

This is a For-Profit Agency Information Submission Form required by the Pennsylvania Department of Human Services (DHS) for contractors operating state-funded programs. The form serves as a quarterly reporting and contact information document for for-profit agencies that have been awarded DHS contracts. Contractors must complete the form with their exact corporate name, federal and local tax identification numbers, Philadelphia business privilege license number if applicable, and designate key personnel including the executive director, fiscal director, board president, and diversity spend monitor. The form requires submission on a quarterly basis and must be signed and dated by the executive director, affirming the accuracy of all information provided at the time of signature. Any changes to contact information must be reported to the compliance manager immediately throughout the fiscal year.

The form does not specify pricing terms, contract amounts, or service delivery details, as it functions solely as an administrative information collection and verification document. Contractors are required to provide an invoice payment address if different from their corporate address, which will be used for encumbrance documents and payments. The form indicates that this submission is part of DHS's ongoing compliance and monitoring process for contracted agencies, ensuring current and accurate contact information and organizational leadership details are maintained throughout the contract period.