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 Executive Order 129 Source Disclosure 1 Certification of Suspension or Debarment 1 Standardized Board Resolution indicating who is 1 authorized to sign: Contracts and Checks Annex A (including summary sheet and supporting 3 schedules) Annex B Form (Expense Summary, Details –Budget 3 and Schedules 1-6) List of Contracts 1 Equipment Inventory 1 Liability Insurance 1 Bonding Certificate 1 Names, Titles, Addresses and Terms of Board of 1 Directors 1 Copy of Audit Report Current Affirmative Action Certificate or copy of 1 renewal application sent to Treasury (AA302) Chapter 51, Public Law 2005—For-Profit 1 agencies only Federal Funding Accountability and Transparency Act 1 (FFATA) Worksheet (if applicable) 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
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 Executive Order 129 Source Disclosure 1 Certification of Suspension or Debarment 1 Standardized Board Resolution indicating who is authorized to sign: Contracts and Checks 1 Annex A (including summary sheet and supporting schedules) 3 Annex B –Budget Form (Expense Summary, Details and Schedules 1-6) 3 List of Contracts 1 Equipment Inventory 1 Liability Insurance 1 Bonding Certificate 1 Names, Titles, Addresses and Terms of Board of Directors 1 Copy of Audit Report 1 Current Affirmative Action Certificate or copy of renewal application sent to Treasury (AA302) 1 Chapter 51, Public Law 2005—For-Profit agencies only 1 Federal Funding Accountability and Transparency Act (FFATA) Worksheet (if applicable) 1 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
fy15_njcsi_renew.docx