STATE OF NEW JERSEY DIVISION OF FAMILY DEVELOPMENT CONTRACT ADMINISTRATOR: CONTRACT NUMBER: NAME OF AGENCY: CONTRACT PERIOD: INDEX OF REQUIRED CONTRACT DOCUMENTS This index provides details of all required documents that must either be included with the contract package (see checklist) or must be available on site for inspections as noted in the Document Verification Sheet (DVS). Forms that are not included in the following pages, can be found by accessing the website at and clicking on the link for Standard Contract Documents. Document Required with first Contract and as Amended Required Annually and as Amended Checklist Required for on-site - DVS Form Check if submitted with package Contract Documents Standard Language Document (SLD) with original signatures (additional copies requested must also have original signature) 2 copies Annex A (including summary sheet and supporting schedules) 3 copies Annex B – Budget Form with all required forms, schedules, and signatures and required Budget Narrative. 3 copies Executive Order 129 (Public Law 2005, Chapter 92) Source Disclosure Certification Form ● Federal Funding Accountability and Transparency Act (FFATA) Worksheet (if applicable) ● Certification of Suspension and Debarment ● Disclosure of Investment Activities in Iran Form ● Agreements Copies of Subcontract/Consultant Agreement(s) ● Private/Public Donor Agreement (s) for Match Responsibilities ● HIPAA Business Associate Agreement (BAA) ● ● A copy of the Acknowledgement of Receipt of the New Jersey State Policy and Procedures for EEO/AA ● Insurances/Licenses/Certificates Liability Insurance Declaration Page and/or Malpractice Insurance ● Bonding Certificate ●
Applicable Licenses (business and professional licenses) ● Current Affirmative Action Certificate or copy of renewal application sent to Treasury (AA302 – Affirmative Action Employee Information Report) ● Health/Fire Certificates, Certificate of Occupancy ● Page 2 Document Required with first Contract and as amended Required Annually and as Amended Checklist Required for on-site – DVS Form Check if submitted with package . Lease or Mortgage for Property and Equipment ● Certificate of Incorporation ● New Jersey Business Registration Certificate with the Division of Revenue (Public Law 2001, Chapter 134) ● Documents Required for Non Profit Agencies and as applicable for Profit Agencies Dated List of Names, Titles, Addresses, and Terms of Board of Freeholders or Directors ● Copy of the most recently approved Board Minutes ● Agency By-Laws ● Tax Exempt Certification ● ● Form 990 – Return of Organization Exempt From Income Tax ● Documents Required for Profit Agencies only U.S. Corporation Income Tax Return, Form 1120 ● Chapter 51/Executive Order 117 Vendor Certification and Disclosure of Political Contributions (formerly known as Executive Order 134) and copy of NJ Business Registration Certificate (see separate link) Ownership Disclosure Form (Chapter 51) Agency Policies and Organizational Information Organizational Chart ● Personnel Manual and Employee Handbook (including job descriptions of staff) ● Affirmative Action Policy/Plan ● Conflict of Interest Policy ● Procurement Policy ● Equipment Inventory (contract acquires property with DFD funds) ●
Audit Notification of Licensed Public Accountant (NLPA) - include copy of Accountant’s Certification (see separate link) ● Copy of Single Audit or Independent Audit for recent FY ● Other Supporting Documents Annual Report to Secretary of State ● Annual Report – Charitable Organizations ● Page 3 Document Required with first contract Required Annually and as Amended Required for on-site – DVS Form Check if submitted with package ACH – Credit authorization for automatic deposits (for new requests only) ● W-9 Form (for new Agencies only) ● Additional Division/Office Specific Forms Document Verification Sheet (DVS) ● List of Agency Grants / Contracts ● Standard Board Resolution (indicating authorized signatories for contracts) ● Checklist and Copy of Award Letter ● Other: The agency agrees to submit, to the DFD Contract Administrator, any and all changes regarding the information presented in these documents during the term of the contract. All documents should be current and reflect the approval of the agency officials, when applicable. The index is for reference and is not required to be retuned with the contract package. All documents noted here are either included in the Checklist or Document Verification Sheet (DVS). The checklist and DVS must be returned with the contract package. DFD OFFICE OF CONTRACT ADMINISTRATION CONTRACT CHECKLIST CONTRACT ADMINISTRATOR: CONTRACT NUMBER: NAME OF AGENCY: CONTRACT PERIOD: PROVIDER INSTRUCTIONS: This checklist must be completed and returned with all documents prior to contract approval. Forms that are not included in the following pages, can be found by accessing the website at and clicking on the link to Standard Contract Documents.
Document Number of copies to be uploaded Please check if uploaded with package If not uploaded with package, indicate anticipated date of submission or reason for Complete copy of signed DHS Standard Language Document (SLD) 1 Checklist, DVS and Award Letter 1 Executive Order 129 Source Disclosure 1 Certification of Suspension or Debarment 1 Standardized Board Resolution indicating who is authorized to sign: Contracts and Checks 1 Annex A – Parts I and II (including summary sheets, supporting schedules and LOS). 1 Annex B –Budget Form (Expense Summary, Details and Schedules 1-6) and required Budget Narrative. 1 List of Grants / Contracts 1 Contract Acquired Equipment Inventory 1 Liability Insurance 1 Bonding Certificate 1 Names, Titles, Addresses and Terms of Board of Freeholders / Directors 1 Copy of Audit Report 1 Current Affirmative Action Certificate or copy of renewal application sent to Treasury (AA302) 1 Disclosure In Investment Activities in Form 1 Federal Funding Accountability and Transparency Act (FFATA) Worksheet (if applicable) 1 Copies of Subcontracts 1 Document Number of Copies to be uploaded Notification of Licensed Public Accountant (NLPA) (include copy of Accountant’s Certification) 1 Private/Public Donor Agreement for Match Responsibilities 1 Organization Chart 1 Conflict of Interest Policy 1 1
STATE OF NEW JERSEY DIVISION OF FAMILY DEVELOPMENT List of Contracts/Grants Check here if this information already appears on the Annex B, Schedule 2 - Contract Information Form. If so, then it is not necessary to duplicate the information here. Contracting Division/Office Program Name Type of Service Contract Number Contract Term Amount Division/Office Contact Person and Phone Number Provider Agency Contact Person and Phone Number