Contract 1 2 3 Quarterly and Final Financial Reports 1 2 3 Contract Budget Modification 1 2 3 Checks 1 2 3 Other Contract Documents: Program Reports 1 2 3 Note: - Enter Authorized Signatory for the Contract (as authorized by Agency Bylaws or Board Resolution). This is the address where the signed contract and all relevant legal correspondence will be mailed. This should be the individual who signs the SLD (page 23). This may not be the same individual as noted in the Annex A summary sheet. In the event of emergency notification, please include e-mail and fax number. Contract Signatory Title Mailing Address Telephone Number Fax Number E-Mail Address
Contract Number: Program Name: PERFORMANCE OUTCOMES GOALS OBJECTIVES ACTIVITIES PERFORMANCE OUTCOMES 1. 1. 1. 2. 3. 4. 5. 2. 1. 2. 2. 3. 4. 5. 3. 1. 3. 2. 2 . . 1 1
Contract Number: STATE OF JERSEY - DIVISION OF FAMILY DEVELOPMENT Annex A PROGRAM PERSONNEL INFORMATION Program Name: POSITION NAME/TITLE NAME OF EMPLOYEE DAILY HOURS % OF TIME TO (DEGREES, LICENSES, FUNCTIONAL DUTIES FROM TO FT PT % FT PT % FT PT % FT PT % FT PT % FT PT % FT PT % FT PT % FT PT %
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. 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 ●
Complete copy of signed DHS Standard Language Document (SLD) Checklist, DVS and Award Letter 1 Executive Order 129 Source Disclosure Certification of Suspension or Debarment 1 Standardized Board Resolution indicating who is authorized to sign: Contracts and Checks Annex A – Parts I and II (including summary sheets, supporting schedules and LOS). Annex B –Budget Form (Expense Summary, Details and Schedules 1-6) and required Budget Narrative. 3 List of Grants / Contracts 1 Contract Acquired Equipment Inventory Liability Insurance 1 Bonding Certificate 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 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 Conflict of Interest Policy 1 1 Disclosure In Investment Activities in Form 1 As Applicable: