Form A Non-Profit.pdf
PDF 91 KB Posted
- Solicitation number
- 21260730153640
- Issued by
- Philadelphia County, Philadelphia City, Pennsylvania
About this file
This is an OCF/DHS Non-Profit Agency Information Submission Form required for non-profit organizations contracting with the Department of Human Services (DHS) in Philadelphia. The form serves as an information collection document for fiscal year 2026 and requests comprehensive organizational details including the exact corporate name, federal identification number, city tax identification, and Philadelphia Business Privilege License number. Required contacts include the Executive Director, Fiscal Director, Board President, and Diversity Spend Monitor, each with associated phone, fax, and email information. The form also requests clarification of invoice payment addresses if different from the corporate address, with a notation that this address will be used for encumbrance documents and payments.
The submission requires certification by the Executive Director affirming the accuracy of all provided information. The form does not specify contract amounts, service descriptions, performance schedules, or renewal terms, as it functions primarily as a standardized information intake document rather than a solicitation or contract award notice. Submission includes a designated contract number field and quarterly reporting requirement for DHS contract money received, indicating this is part of an ongoing quarterly reporting and compliance process for non-profit agencies maintaining active contracts with the city's Department of Human Services.
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Other files
| File | Type | Posted |
|---|---|---|
| Form A For-Profit.pdf | ||
| Human Services Department.pdf | ||
| RFP Submission Checklist 7-2025 rvsd.pdf | ||
| Philadelphia Tax and Regulatory Status and Clearnance Statement.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: 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
File details come from the government source that posted it. Updated .