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f rtment 1a1e Department of Social &WaHealth Servicesn5 Transforming lives New Contractor Intake Section One: Contractor NameBusiness Organization (DSHS staff enter on ACD Intake Detail screen) 1. CONTRACTOR NAME DBA OR FACILITY NAME 2. BUSINESS ORGANIZATION ❑ Individual or Sole Proprietor ❑ General Partnership ❑ Non -Profit Corporation (Attach a copy of 501(c) status) ❑ Limited Liability Partnership (LLP) ❑ For Profit Corporation ❑ Limited Liability Limited Partnership (LLLP) ❑ Faith Based (FBO) Non -Profit Corporation ❑ Limited Liability Company, filing as a Corporation ❑ Faith Based (FBO) Unincorporated ❑ Limited Liability Company, filing as a Partnership ❑ Governmental Entity ❑ Limited Liability Company, filing as a Sole Proprietor 3. ❑ Foreign Person or Entity If your business is NOT a sole proprietorship, attach a list of the partners, members, directors, officers, and board members. iAXPAYFR IDENTIFICATION NUMBER (TIN) Enter your TIN in the appropriate box. • For individuals, this may be your Social Security Number (SSN). • For other entities, it is your Employer Identification Number. Social Security Number (Enter all 9 numbers, OR NO DASHES) Employer Identification Number (Enter all 9 numbers, 4. DEFAULT REPORTED, DETERMINATION OF CONTRACTOR STATUS, WAIVER CERTIFICATION LICENSE, AND UEI NUMBER NO DASHES ___ FISCAL YEAR, UBI NUMBER, BUSINESS Have you had any contract with the state terminated for default? ❑ Yes ❑ No If yes, attach a list of terminated contracts with an explanation why each contract was terminated. Are you or any member of your staff a current employee of DSHS? ❑ Yes ❑ No If yes, attach a brief explanation describing you or your employees duties as a DSHS employee. Does your business require its employees to sign or agree to, as a condition of employment, mandatory individual arbitration clauses or class or collective action waivers? ❑ Yes ❑ No Is your fiscal year end the same as the calendar year (January 1 through December 31)? ❑ Yes ❑ No If the answer is no, what is your fiscal year end date? What is your Washington State Uniform Business Identifier (UBI) Number? (Enter all 9 numbers, NO DASHES) Attach a copy of your current Washington State Master Business incense or explain below why you are exempt from registering your business with the State of Washington. (See page 1 for information on exemptions.) What is your Unique Entity Identifier (UEI) number? (Enter all numbers, NO DASHES). f Y Section Two: Contractor Primary Address (DSHS staff enter on ACD Intake Detail screen) CONTRACTOR PRIMARY ADDRESS (NUMBER, STREET, AND APARTMENT OR SUITE NUMBER) CITY, STATE, AND ZIP CODE EMAIL ADDRESS ' COUNTY WHERE PRIMARY ADDRESS IS (FOR OUT-OF-STATE CONTRACTORS) PHONE NUMBER (INCLUDE AREA CODE) FAX NUMBER (INCLUDE AREA CODE) NEW CONTRACTOR INTAKE Page 2 of 4 DSHS 27-043 (REV. 04/2023)