RFQQ_2413-855_Att_G_DVR_Addi_Contractor_Info.pdf

DVR ADDITIONAL CONTRACTOR INFORMATION Page 1 of 2

DSHS 27-175 (REV. 04/2024)

DIVISION OF VOCATIONAL REHABILITATION

DVR Additional Contractor Information

1. Contractor Information. Please PRINT clearly in all boxes, except for signature box.

CONTRACTOR NAME AS REGISTERED WITH THE IRS

CONTRACTOR DBA (IF ANY) FOR THIS CONTRACT

2. Contracting Information

A. Years of experience your organization has providing the type of services purchased through this contract?

years

B. Is this the first contract with DSHS or other state agencies for your organization? Yes No

B.1. Has your organization ever acted as subcontractor for DSHS or another public agency? Yes No

B.2. Is your organization currently or has your organization been the subject of any investigation or finding(s) due to a DSHS or other public agency investigation regarding the performance of a criminal act, abridgement of human rights, or improper billing practices? Yes No

If YES, please provide details below or on a separate sheet of paper.

B.3. Has your organization had a contract terminated for default by DSHS or other public agencies? Yes No If “Yes,” please include the termination letter when you return this form to DVR.

Please list the contract numbers for the contract(s) where there has been a default action taken on Page 2.

B.4. Has your organization received audit findings related to any public contracts which your agency was a party to in the past two (2) years? Yes No

B5. Has your organization done business under any other business name, Employer Identification Number (EIN), or Washington State Unified Business Identifier (UBI)? Yes No

If “Yes,” please list any other identifiers under which you have done business on Page 2.

C. Do you currently have other active DSHS, state agency, or other government contracts?

Yes (how many: ) No

C.1. Do you have contract(s) or receive funds for the provision of similar services as purchased through this contract?

Yes No

If “Yes,” please list the additional sources and contracts on Page 2.

3. Contractor Financial Information

Please provide your company’s Statewide Vendor Number (SWV) as assigned by the Office of Financial Management (OFM): SWV number If you have not yet received a SWV number, please provide the date you submitted the registration paperwork to DES:

4. Signature

CONTRACTOR’S SIGNATURE DATE

PRINTED NAME

TITLE

DVR ADDITIONAL CONTRACTOR INFORMATION Page 2 of 2

DSHS 27-175 (REV. 04/2024)

Supplemental Information Using the following table, please fill out any requested information from the previous page.

Please include the Contract Number, Other Business Name(s), EIN, UBI, and Funding Source for the Provision of Similar Services for each item listed under rows 1 – 4 in the Contractor Additional Information column.

If the information from the Contractor Additional Information column does not apply, please include “N/A” in the following columns.

Contractor Additional Information Contract Number Other Business Name(s), EIN, UBI

Funding Source for the Provision of Similar

Services Default Action(s):

Audit Finding(s):

Past Business Identification:

Additional Contracts or Sources of Funding: