Enter all data requested in the form. Enter Agency Official responsible for the program administration. Authorized Signatories Enter Authorized Signatory for the Contract (as authorized by Agency Bylaws or Board Resolution). IMPORTANT - This is the address where the signed contract and all relevant legal correspondence will be mailed so please ensure this is the accurate address. – Service Delivery Information Please complete all details for the service delivery STATE OF NEW JERSEY - DIVISION OF FAMILY DEVELOPMENT ANNEX A CONTRACT SUMMARY SHEET FY 16 SSI – – Contract ICCP Provider Agency # Mailing Address Federal # Telephone Number Provider Agency Fiscal Year End Agency 7/1/15 6/30/16 Contract Effective to Contract $ Date Ceiling Organization Agency Type Board of Social Services CWA Non-Profit
Enter all data requested in the form. Enter Agency Official responsible for the program administration. Authorized Signatories Enter Authorized Signatory for the Contract (as authorized by Agency Bylaws or Board Resolution). IMPORTANT - This is the address where the signed contract and all relevant legal correspondence will be mailed – so please ensure this is the accurate address. Service Delivery Information Please complete all details for the service delivery STATE OF NEW JERSEY - DIVISION OF FAMILY DEVELOPMENT ANNEX A – CONTRACT SUMMARY SHEET – FY 16 SSI Provider Agency Contract # ICCP Mailing Address Federal # Telephone Number Provider Agency Fiscal Year End Agency Contract Effective Date 7/1/15 to 6/30/16 Contract Ceiling $ Organization Type Agency Board of Social Services CWA Non-Profit
fy16_ssi_annxa.docx