Form A Non-Profit.pdf
PDF 91 KB Posted
- Solicitation number
- 21260602084904
- Issued by
- Philadelphia County, Philadelphia City, Pennsylvania
About this file
This is a Non-Profit Agency Information Submission Form for the Department of Human Services (DHS) in Pennsylvania, designed to collect essential organizational and contact information from non-profit entities receiving DHS contract funding. The form requests submission during fiscal year 2026 and requires organizations to provide their exact corporate name, federal identification number, city tax ID, Philadelphia Business Privilege License number, and the amount of DHS contract money received in the submission quarter. The form designates specific contact personnel including the Executive Director, Fiscal Director, Board President, and Diversity Spend Monitor, with corresponding phone, fax, and email information for each position.
The form requires organizations to confirm their corporate address for general correspondence and specify an alternate address if invoice payments should be directed elsewhere, with particular emphasis on accuracy for encumbrance documents and payments. The submission must be executed by the Executive Director with a signature and date, certifying that all provided information is accurate. This form serves as a quarterly reporting and compliance document that maintains current organizational records for non-profit agencies contracted with DHS to provide services, including forensic behavioral health evaluations for child welfare involved individuals and families.
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Text version
DATE OF SUBMISSION: CONTRACT #: __________________________
FISCAL YEAR: 2026 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.)
I affirm that the information provided is accurate for all
Signature of Executive Director:_________________________________________________________________________ Date:______________________________
OCF/ DHS Non-Profit Agency Information Submission Form
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