Form A For-Profit.pdf
PDF 89 KB Posted
- Solicitation number
- 21260730153640
- Issued by
- Philadelphia County, Philadelphia City, Pennsylvania
About this file
This is an Agency Information Submission Form for For-Profit entities contracting with the Department of Human Services (DHS) in Philadelphia. The form serves as a standardized information collection document for for-profit contractors to submit required organizational and contact details to DHS. The form requires submission of basic corporate information including the exact legal corporate name, federal identification number, and Philadelphia-specific tax identifiers such as City Tax ID and 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 provided. Additionally, contractors must specify a payment address if different from the corporate headquarters address, which will be used for encumbrance documents and invoice payments.
The form is designed to establish and maintain current contractor information within the DHS compliance and financial systems. Contractors are required to affirm the accuracy of submitted information at the time of signature by the Executive Director, with an obligation to submit updated forms to their compliance manager immediately upon any changes to contact information throughout the fiscal year. The document includes fields for tracking the submission date, associated contract number, fiscal year, quarter, and the amount of DHS contract money received during the reporting period, indicating this is a recurring quarterly reporting requirement for for-profit vendors managing state contracts.
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Other files
| File | Type | Posted |
|---|---|---|
| Human Services Department.pdf | ||
| RFP Submission Checklist 7-2025 rvsd.pdf | ||
| Philadelphia Tax and Regulatory Status and Clearnance Statement.pdf | ||
| Form A Non-Profit.pdf | ||
| Local Business Entity Cert.pdf | ||
| FY27 Budget template non CUA .xlsx | XLSX spreadsheet | |
| Dependent GH RFP fy27 Males dwj.pdf | ||
| LGBTQ Data Form.pdf |
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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.
File details come from the government source that posted it. Updated .