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 As Applicable: ACH Credit authorization for automatic deposits – 1 (for new requests only) W-9 Form (for new providers) 1 Purchase and Property Disclosure Form (Iran Other: 1 Form) 1 NEW JERSEY DEPARTMENT OF HUMAN SERVICES DIVISION OF FAMILY DEVELOPMENT
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 As Applicable: ACH – Credit authorization for automatic deposits (for new requests only) 1 W-9 Form (for new providers) 1 Other: Purchase and Property Disclosure Form (Iran Form) 1 1 NEW JERSEY DEPARTMENT OF HUMAN SERVICES DIVISION OF FAMILY DEVELOPMENT
fy15refugee_serviceandhealth_rshp.docx