Doing Business As Name (DBA) or Parent Organization Indicate if different from Legal Name above Attach a copy of Assumed Name Certificate If an Applicant has a Parent Organization, attach a copy of the agreement between the Applicant and the Parent Organization Mailing Address - If different from Office Address above Applicant: Parent Organization:_ Federal ID Number – If different from Vendor ID Applicant: Parent Organization: Social Security Number - If applying as Individual/Sole Proprietor Name of Person Authorized to Sign Contract Title Phone Number: Email: Name of Person Responsible for Billing Title Phone Number: Email: Type of Applicant – Check appropriate box(es) and attach documentation as indicated Are you applying to provide services to DFPS? Yes No Governmental Entity Do you have taxing authority? Yes No Private Corporation For Profit Non-Profit State of Incorporation: Charter Number: Attach a copy of Certificate of Incorporation Limited Liability Company (LLC) Attach a copy of the Articles of Incorporation
(If in operation for one or more years) Applicant Provides 03.B-Changes in Financial Position Statement of Changes in Financial Position (If in operation for one or more years) Yes Applicant Provides 03.C-Cash Flow Cash Flow Statement (If in operation for one or more years) Yes Applicant Provides 03.D-Expenditures Capital Expenditures (If available and in operation for one or more years) Yes Applicant Provides 03.E-Audit Annual Audit (If in operation for one or more years) Yes, if available. Applicant Provides 03.F-Budget 12-Month Projected Budget of Income and Expenses (If in operation for less than one year) Yes Applicant Provides 03.G-Funds Reserve Funds or Available Credit for two months of Operation (If in operation for less than one year) Yes Applicant Provides 03.H-IRS Reporting Forms Annual Internal Revenue Service (IRS) reporting Forms 990; 1065; 1120; and 1040C; 940; and 941 Yes, if Applicable. Applicant Provides 03.I-Change Impacting Ownership Change impacting ownership within 12 months prior to Application submission or is anticipated during the 12 months following submission Yes, if Applicable. FILE FOLDER 3: Required Forms Document Location ELECTRONIC FILE NAME Document Is Document Required Yes/No
Progress reports; school reports; Medication monitoring reports; Serious incidents reports; Case management notes; and Daily logs or documentation by foster parents. Document Location ELECTRONIC FILE NAME Document Is Document Required Yes/No Applicant Provides 01-License DFPS License or acceptance letter Yes Applicant Provides 02-Model and Philosophy Program Model and Philosophy Yes Applicant Provides 02.A-Policies and Procedures Complete Set of Program Policies and Procedures Yes Applicant Provides 02.B-Substance Abuse Substance Abuse Policy and Procedure Yes Applicant Provides 03-Program Components Description of All Program Components Including Behavioral and Therapeutic Interventions Yes Applicant Provides 04-Children’s Orientation Children’s Rules, Rewards, Consequences and/or Orientation Manual/Handbook Yes Applicant Provides 05-Daily Schedules Example of Daily Schedules for School Year, Summer and Weekends Yes Applicant Provides 06-Recreation Schedule Example of Recreation Schedule Yes Applicant Provides 07-Therapeutic Value Description of Recreational Program, including its therapeutic value Yes Applicant Provides 08-School Relationship Written description of the relationship with the school system Yes Applicant Provides 09-Observation Plan to Provide Direct, Continuous Observation of a Child Who May Be at Risk for Harming Self or Others, and Yes