Appendix D - Application and Plan for Human Services Program Cover Page

APPENDIX D
Application and Plan for Human Services Program
Cover Page

Official Form: Application and Plan for Human Services Program (pdf)

The webversion of this form is for ADA purposes. Please fill out the PDF version.

Truancy Review Boards RFP (FY2010) (pdf)

  1. APPLICANT ORGANIZATION:
    • NAME:
    • ADDRESS:
    • TELEPHONE:
    • E-MAIL:
    • TIN/FEIN NUMBER:
      *Attach IRS Form 575K or Form W-9, when applicable
  2. DATE OF SUBMISSION: Month / Day / Year
  3. APPLICANT CERTIFICATION:
    To the best of my knowledge, the data and statements in this application are true and correct. The applicant agrees to comply with all State/Federal statutes and Rules/Regulations applicable to the program.
  4. PROJECT PERIOD:
  5. TYPE OF ORGANIZATION:
    • Governmental Entity
    • *Not-For-Profit Corporation
    • Corporation
    • Medical/Health Care Provider Corporation
    • *Tax Exempt Organization (IRC 501(a) only)
    • * Must provide documentation of current status
  6. LEGISLATIVE DISTRICT:
    • CONGRESSIONAL:
    • LEGISLATIVE:
      (State Senate District)
    • REPRESENTATIVE
      (State Representative District)
  7. IMPORTANT NOTICE:
  8. FOR DEPARTMENT USE ONLY:

AUTHORIZED OFFICIAL:

  • Typed name
  • Title
  • Signature Date

INSTRUCTIONS FOR COMPLETING
"APPLICATION AND PLAN FOR HUMAN SERVICES PROGRAM"

All applications shall be submitted as required in the Request for Proposal or other instructions distributed by DHS.

  1. Provide applicant name and address as it is to appear in the contracts for services that will be developed for successful applicants.
    • TIN number: Provide the applicant's nine-digit federal Taxpayer Identification Number (also known as the Federal Employer Identification Number, 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.
    • Applicants not currently receiving funding from the Division of Community Health and Prevention should attach a copy of the applicant's Internal Revenue Service (IRS) Form 575K, Notice of New Employee Identification Number Assigned, or an IRS Form W-9 in which the applicant's name and TIN number is consistent with the information on record with the Secretary of State and the IRS.
  2. Enter the date the application is forwarded to the Department.
  3. 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.
    • Signature of "Authorized Official" certifies compliance with all requirements as described in the Request for Proposal, applicable program Rules and Regulations and applicable state and federal Rules and Regulations.
  4. Enter the project period to be covered by this application, if different than that indicated.
  5. Mark (X) to indicate the 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.
  6. Provide the appropriate district numbers for the area(s) to be served.