Form A Non-Profit.pdf

This is a Non-Profit Agency Information Submission Form required by the Pennsylvania Department of Human Services (DHS) for organizations operating state-funded contracts. The form is submitted on a quarterly basis and requires non-profit agencies to provide current organizational information including exact corporate name, federal identification number, city tax identification number, Philadelphia Business Privilege License number, and complete contact details for key personnel including the Executive Director, Fiscal Director, Board President, and Diversity Spend Monitor. The submission must include the contract number, fiscal year, quarter, and the exact amount of DHS contract money received during that quarter. Additionally, agencies must provide their corporate address and specify any alternative address to be used for encumbrance documents and invoice payments if different from the registered corporate address.

The form serves as an information verification and accountability mechanism for non-profit agencies receiving DHS funding, ensuring accurate records for contract administration and financial tracking purposes. The Executive Director must affirm the accuracy of all information provided and sign and date the submission. This quarterly reporting requirement applies to all non-profit organizations contracted with DHS to deliver services, including those operating emergency shelter programs and other human services initiatives. The form does not specify pricing terms, set-asides, or contract award dates but functions as an ongoing compliance and administrative documentation requirement throughout the contract term.