REQ - Subcontractor Listing contracted services NON direct care.pdf
PDF 213 KB Posted
- Solicitation number
- BD-27-1031-BCHAP-BCH01-133140
- Issued by
- Massachusetts
About this file
This is a Subcontractor Identification List form for Non-Direct Care Services issued by the Commonwealth of Massachusetts Department of Public Health (DPH). The form is used to identify and document subcontractors that provide deliverables constituting a primary and integral part of contracted programs. Vendors must complete and submit this form at the time of initial contract execution and whenever subcontract dollars and/or vendors are added, deleted, or adjusted. The form requires annual completion for each fiscal year when subcontracted funds are budgeted and must be submitted with any contract amendments. All subcontracts must be in writing in accordance with Commonwealth Terms and Conditions, available for review by authorized Commonwealth agents, and subject to submission requirements at any time during the contract period. Subcontractors must agree to the terms and conditions of the supportive procurement, which is incorporated into the overall contract.
The form requires vendors to identify each subcontractor by name and Federal Employer Identification Number (FEIN), specify the subcontract amount, and provide a description of services provided in fewer than 200 words. Amounts identified as "TBD" require quarterly status updates from the Procurement and Operations System (POS). The total subcontractor amount must align with the subcontractor section of the NON EIM PP HH budget sheet or Line 206 of the M04/M78 Budget. The form must be signed by both the vendor and DPH program manager prior to subcontract execution. Individuals are not recorded on this form. This documentation requirement applies to contracts with the Massachusetts Department of Public Health, including the Comprehensive Sexual and Reproductive Health Program identified in the related contract opportunity.
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Text version
Subcontractors must agree to the Terms and Conditions set forth in the supportive procurement, which is part of this contract. Subcontracts must be in writing, in accordance with Section 9 of the Commonwealth Terms and Conditions or the Commonwealth Terms and Conditions for Human and Social Services. Vendors may use a standard subcontract template available through DPH contract managers. All subcontracts must be available for review by authorized agents of the Commonwealth. DPH may require the submission of any subcontract at any time during the contract period.
Updated:01/30/2025
SUBCONTRACTOR IDENTIFICATION LIST FOR NON-DIRECT CARE SERVICES
Deliverables which are a primary and integral part of the total program but which are furnished to the program, under contract, by another provider.
Vendor Name: DPH Program Name:
COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF PUBLIC HEALTH
FY
Contract ID
Submitted by: Date: Phone:
Provider/Vendor Authorized Signature
Print Name
Approved by: Date: Phone:
DPH Program Manager
Print Name
INSTRUCTIONS:
Vendors must complete and submit to DPH at the time of initial contract execution AND when subcontract dollars and/or vendors are added or deleted. (Including line item adjustments).This form must be signed by the DPH program representative to indicate program approval PRIOR TO the execution of said subcontract(s).
• Vendors are to complete this form each fiscal year when subcontracted $ are budgeted.
• Vendors are to complete this form with any amendments.
• Identify the Subcontractor and Federal ID number along with $ amounts and description of service provided in less than 200 words (Individuals are not recorded on this form)
• $ identified as TBD will require status updates which POS will request quarterly
Subcontractor Name FEIN Subcontract Amount Deliverable TBD
TOTAL $
This total # must = the total amount on subcontractor section of the NON EIM PP HH budget sheet or 206 Line of the M04/M78 Budget
| FY: |
| Contract ID: |
| Date: |
| Phone: |
| Print Name: |
| Approved by: |
| Date_2: |
| Phone_2: |
| Print Name_2: |
| Subcontractor NameRow1: |
| FEINRow1: |
| Deliverable: |
| undefined: |
| Subcontractor NameRow2: |
| FEINRow2: |
| undefined_2: |
| Deliverable_2: |
| Subcontractor NameRow3: |
| FEINRow3: |
| undefined_3: |
| Deliverable_3: |
| Subcontractor NameRow4: |
| FEINRow4: |
| undefined_4: |
| Deliverable_4: |
| Subcontractor NameRow5: |
| FEINRow5: |
| undefined_5: |
| Deliverable_5: |
| Subcon_AM_1: |
| Subcon_AM_2: |
| Subcon_AM_3: |
| Subcon_AM_Tot: 0 |
| Subcon_AM_4: |
| Subcon_AM_5: |
| Check Box2: Off |
| Check Box3: Off |
| Check Box4: Off |
| Check Box5: Off |
| Check Box6: Off |
| Submitted by: |
| Vendor_Name: |
| Program_Name: |
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