Form A For-Profit.pdf
PDF 89 KB Posted
- Solicitation number
- 21260714131255
- Issued by
- Philadelphia County, Philadelphia City, Pennsylvania
About this file
This is a For-Profit Agency Information Submission Form required by the City of Philadelphia Department of Human Services (DHS) for contractors receiving DHS contract funds. The form serves as a quarterly reporting and compliance document for for-profit entities engaged with the department, specifically related to a contract opportunity involving the Division of Juvenile Justice Services (JJS) that seeks qualified applicants to provide comprehensive vocational training and career development services in Pennsylvania.
The form requires submission of essential contractor information including the exact corporate name, federal identification number, city tax identification number, and Philadelphia Business Privilege License number. Contractors must designate primary contacts for four key roles: Executive Director, Fiscal Director, Board President, and Diversity Spend Monitor, with corresponding phone, fax, and email information for each. The form also requires confirmation of the payment invoice address if different from the corporate address, as this address will be used for encumbrance documents and payments. Contractors must certify the accuracy of all information provided at the time of signature and commit to submitting updated versions immediately if any contact information changes throughout the fiscal year. The form requests quarterly reporting of DHS contract money received during the specified fiscal year quarter.
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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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