Required Required Check if Required for on-site Annually submitted Document Page 3 with first and as with contract DVS – Amended package Form ACH Credit authorization for automatic deposits – ● (for new requests only) W-9 Form (for new Agencies only) ● Additional Division/Office Specific Forms Document Verification Sheet (DVS) ● List of Agency Grants / Contracts ● Standard Board Resolution (indicating authorized signatories for ● contracts) Checklist and Copy of Award Letter ● Other: The county agency agrees to submit, to the DFD Contract Administrator, any and all changes regarding the information presented in these documents during the term of the contract. All documents should be current and reflect the approval of the county officials, when applicable. The index is for reference and is not required to be retuned with the contract package. All 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 CONTRACT ADMINISTRATOR: NUMBER: NAME OF CONTRACT AGENCY: 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. Number of If not submitted with Please check if copies to package, indicate anticipated Document submitted with be date of submission or reason package submitted for non-submission Complete copy of signed DHS Standard Language 2 Document (SLD) Checklist, DVS and Award Letter 1
Page 3 Document Required with first contract Required Annually and as Amended Required for on-site – DVS Form Check if submitted with package ACH – Credit authorization for automatic deposits (for new requests only) ● W-9 Form (for new Agencies only) ● Additional Division/Office Specific Forms Document Verification Sheet (DVS) ● List of Agency Grants / Contracts ● Standard Board Resolution (indicating authorized signatories for contracts) ● Checklist and Copy of Award Letter ● Other: The county agency agrees to submit, to the DFD Contract Administrator, any and all changes regarding the information presented in these documents during the term of the contract. All documents should be current and reflect the approval of the county officials, when applicable. The index is for reference and is not required to be retuned with the contract package. All 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 check 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
fy17_ssh_annex_a.docx