Note 1 - 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
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 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 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 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 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 DOCUMENT VERIFICATION SHEET (DVS) Contract Number Contract Period The Provider Agency hereby certifies that the following documents are on file and are available to the Division of Family Development (DFD) for review. The contracting Provider Agency also agrees that it will inform the DFD contract administrator of any and all changes involving these documents that may occur during the term of the contract. All documents should be current and reflect board approval. Please do not submit documents listed below with renewal package. Please Check as Appropriate On File Not Applicable Certificate of Incorporation and NJ Business Registration Certificate (filed with the Division of Revenue) Annual Report to Secretary of State and Ownership Disclosure Form
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