Form A Non-Profit.pdf
PDF 91 KB Posted
- Solicitation number
- 21260714131255
- Issued by
- Philadelphia County, Philadelphia City, Pennsylvania
About this file
This is a Non-Profit Agency Information Submission Form required by the City of Philadelphia Department of Human Services (DHS) for organizations contracting with the department. The form serves as a quarterly reporting document for non-profit agencies receiving DHS contract funding, specifically related to the Division of Juvenile Justice Services (JJS) which seeks qualified applicants to provide comprehensive vocational training and career development programs. Submission requires identification of the contract number, fiscal year, and quarter for which the form is being submitted, along with documentation of the exact amount of DHS contract money received during that quarter.
The form mandates comprehensive organizational information including the exact corporate name, corporate address, Federal ID number, City Tax ID number, and Philadelphia Business Privilege License number. Required contact information includes details for the Executive Director, Fiscal Director, Board President, and Diversity Spend Monitor, with phone, fax, and email for each position. The form requires specification of a payment address if different from the corporate address, as this address will be used for encumbrance documents and payments. Submission must include the signature and date of the Executive Director affirming the accuracy of all information provided, establishing accountability for the reported data.
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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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