Attachment A - Application and Plan for Human Services Program Cover Sheet Instructions

APPLICATION AND PLAN FOR HUMAN SERVICES PROGRAM COVER SHEET INSTRUCTIONS

1. Applicant Organization - Provide applicant name and address as it is to appear in the contracts for services which will be developed for successful applicants.
   • FEIN Number - Provide your nine-digit Federal Taxpayer Identification Number (also known as the Federal Employer Identification Number, or FEIN) or the state assigned Governmental Unit Code. Governmental agencies (county or municipality) should use the Governmental Unit Code, which generally begins with 20 or 30; non-governmental agencies or multi-county agencies should use the FEIN, which generally begins with 36 or 37.
   • DUNS Number - Provide your nine-digit Data Universal Numbering System (DUNS) Number.  If your agency does not have a DUNS Number, you must get one. Go to http://www.dhs.state.il.us/page.aspx?item=56807 and click on "How to Get a DUNS Number". This will connect to the Dun & Bradstreet website and it will lead you through a process to obtain a number.
   • CAGE Number - Provide your five-character Commercial and Government Entity (CAGE) Identification number. To get a CAGE code, you must first complete the Department of Defense's Central Contractor Registration (CCR), which is a requirement for doing business with the federal government. CCR applications are available at http://www.ccr.gov/Start.aspx.  You will be assigned your CAGE code as part of the CCR validation process, and as soon as your CCR registration is active, you can view your CAGE code online when you log in to your CCR account.
   • CCR Expiration Date - Please provide the date on which your registration expires.
2. Date of Submission - Enter the date the Application is forwarded to the Department.
3. Project Period - Enter the project period to be covered by this Application, if different from that indicated.
4. Type of Organization - Mark (X) to indicate your type of organization. Documentation of current status, such as a certificate of good standing from the Secretary of State or other comparable proof of status, must be provided for all applicants other than governmental entities.
5. Category of Domestic Violence Service & Dollars Requested From IDHS - Mark (X) to indicate the category of service you are proposing to provide. Category definitions are included in Part II, check one category only. State the dollar amount you are requesting from IDHS for the project period-July 2012 thru June 2013.
6. Legislative District - Provide the appropriate district numbers for the area(s) to be served. Information regarding Congressional Districts is available at http://www.house.gov; State Legislative Districts are available at http://www.ilga.gov.
7. Important Notice - Please read in its entirety.
8. Applicant Certification - Provide the name and title of the person authorized to enter into contracts or otherwise obligate the agency to provide services. This information will be used for the signature block for contracts offered to successful applicants. The signature of the authorized official certifies compliance with all requirements, as described in the Request for Application, applicable program rules and regulations, and applicable state and federal rules and regulations.