Instructions Program Summary Enter the information on the site where services for this program are provided. Contract Summary Sheet Enter Agency Name, Address, Telephone and Contract No., Federal Identification No., Contract effective dates (as noted in the DFD contract award letter) and contract ceiling (per Annex B). Enter CEO and Agency notice information. All data must be completed. Authorized Signatories Enter Authorized Signatory for the Contract (as authorized by Agency Bylaws or Board Resolution). IMPORTANT - This is the address where the signed contract and all relevant legal correspondence will be mailed – so please ensure this is the accurate address. Service Delivery Information Service will be provided as follows for each day of the week, enter the hours the agency will provide contracted services. Please indicate if there is a difference among any of the contracted services in the program specific narrative. Emergency Provisions Describe any special arrangements which have been made to handle emergencies, e.g. voice mail instructions, special telephone numbers etc. Service will not be provided on the following occasions List the occasions and dates when service will not be provided, e.g. December 25-Christmas, July 4-Independence Day, etc. Program Narrative *Please see specific instructions attached to this section
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. The correct number of copies and any additional Division documents must be returned to your Contract Administrator. 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 submitted Please check if submitted with package If not submitted with package, indicate anticipated date of submission or reason for non-submission Complete copy of signed DHS Standard Language Document (SLD) 2 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 (including summary sheet and supporting schedules) 3 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
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