Form A Non-Profit.pdf

This is a Non-Profit Agency Information Submission Form for the Pennsylvania Department of Human Services (DHS) related to group home care contracting for dependent adolescents ages 13-21. The form serves as an information collection document for non-profit agencies seeking to establish or maintain contracts with DHS during fiscal year 2026. The submission requires organizations to provide their exact corporate name, federal identification number, city tax identification number, Philadelphia Business Privilege License number, and contract identification number. Key contact information must be documented for the Executive Director, Fiscal Director, Board President, and Diversity Spend Monitor, including phone numbers, facsimiles, and email addresses. Organizations must also specify the exact address for invoice payments if different from the corporate address, as this information will be used for encumbrance documents and processing payments.

The form requires submission within a specified quarter of fiscal year 2026 and must document the exact amount of DHS contract money received during that quarter. The submitting organization's Executive Director must affirm the accuracy of all information provided through signature and date notation. This form appears designed to maintain current and accurate organizational data for non-profit agencies already engaged in or applying for DHS contracts for adolescent group home care services. The submission process ensures DHS maintains comprehensive records of contractor information necessary for payment processing, diversity monitoring, and contract administration purposes.