Copies of Subcontracts 1 Document Number of Copies to be submitted Notification of Licensed Public Accountant (NLPA) 1 (include copy of Certification) Accountant’s Private/Public Donor Agreement for Match 1 Responsibilities 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 – 1 (for new requests only) W-9 Form (for new providers) 1 Other: Purchase and Property Disclosure Form (Iran 1 Form) 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. Not Please Check as Appropriate On File 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 Annual Report - Charitable Organization
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 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 Annual Report - Charitable Organization