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 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 ● 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 or Continued 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 ●
Annex B –Budget Form (Expense Summary, Details and Schedules 1-6) 3 List of Contracts 1 Equipment Inventory 1 Liability Insurance 1 Bonding Certificate 1 Names, Titles, Addresses and Terms of Board of Directors 1 Copy of Audit Report 1 Current Affirmative Action Certificate or copy of renewal application sent to Treasury (AA302) 1 Chapter 51, Public Law 2005—For-Profit agencies only 1 Federal Funding Accountability and Transparency Act (FFATA) Worksheet (if applicable) 1 Copies of Subcontracts 1 Document Number of Copies to be submitted Notification of Licensed Public Accountant (NLPA) (include copy of Accountant’s Certification) 1 Private/Public Donor Agreement for Match Responsibilities 1 Organization Chart 1 W-9 Form (for new provider only) 1 Conflict of Interest Policy 1 1 As Applicable: ACH – Credit authorization for automatic deposits (for new requests only) 1 W-9 Form (for new providers) 1 Other: Purchase and Property Disclosure Form (Iran Form) 1 1 NEW JERSEY DEPARTMENT OF HUMAN SERVICES DIVISION OF FAMILY DEVELOPMENT
STATE OF NEW JERSEY DIVISION OF FAMILY DEVELOPMENT List of Contracts/Grants Check here if this information already appears on the Annex B, Contract Information Form. If so, do not duplicate 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