Audit Notification of Licensed Public Accountant (NLPA) - include copy ● of Certification (see separate link) Accountant’s Copy of Single Audit or Independent Audit for recent FY ● Other Supporting Documents Annual Report to Secretary of State ● Annual Report Charitable Organizations – ● 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 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 agency 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. 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.
Audit Notification of Licensed Public Accountant (NLPA) - include copy of Accountant’s Certification (see separate link) ● Copy of Single Audit or Independent Audit for recent FY ● Other Supporting Documents Annual Report to Secretary of State ● Annual Report – Charitable Organizations ● 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 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 agency 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. 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.
fy17_ssi_annex_a.docx