ANNEX A CONTRACT SUMMARY SHEET – Provider Agency Contract# Mailing Address Federal IIIDID # Telephone Number Provider Agency Fiscal Year End County Contract Effective Date to Contract Ceiling $ Organization Type County Board of Social Services Non-Profit Program Administration Details: Chief Executive Title Mailing Address Telephone Number Fax Number E-Mail Address All routine notices relevant to the Name & Title administration of the Mailing Address program should be sent to: Telephone Number Fax Number E-Mail Address Do you certify that all information is read, understood and correct? Agency Authorized Signature: ___________________________________ Date: __________ Division of Family Development Annex A -Service Delivery Information
ANNEX A – CONTRACT SUMMARY SHEET Provider Agency Contract# Mailing Address Federal IIIDID # Telephone Number Provider Agency Fiscal Year End County Contract Effective Date to Contract Ceiling $ Organization Type County Board of Social Services Non-Profit Program Administration Details: Chief Executive Title Mailing Address Telephone Number Fax Number E-Mail Address All routine notices relevant to the administration of the program should be sent to: Name & Title Mailing Address Telephone Number Fax Number E-Mail Address Do you certify that all information is read, understood and correct? Agency Authorized Signature: ___________________________________ Date: __________ Division of Family Development Annex A -Service Delivery Information
fy18_ccrr_annx_1.docx