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2. ADDITIONAL STAFF: IF YOU HAVE MORE THAN TWO ADDITIONAL STAFF (LISTED BELOW), WHO ARE ALSO RELEVANT TO YOUR DSHS CONTRACTS, PLEASE PROVIDE INFORMATION ABOUT THOSE STAFF ON A SEPARATE PAGE. Additional staff person is a(n): ❑ Officer or Board Member ❑ Other (please identify) _ ❑ Partner ❑ Staff Member ❑ Elected Official Is the additional staff authorized to sign contracts? Is the additional staff a contact for DSHS contracts? ADDITIONAL STAFF NAME AND TITLE PHONE NUMBER (INCLUDE AREA CODE) Additional staff person is a(n): ❑ Officer or Board Member ❑ Other (please identify) (DSHS staff enter as applicable on ACD) ❑ Yes ❑ No ❑ Yes ❑ No ADDITIONAL STAFF EMAIL ADDRESS FAX NUMBER (INCLUDE AREA CODE) CELLULAR PHONE NUMBER (INCLUDE AREA CODE) ❑ Partner ❑ Staff Member ❑ Elected Official (DSHS staff enter as applicable on ACD) Is the additional staff authorized to sign contracts? ❑ Yes ❑ No Is the additional staff a contact for DSHS contracts? ❑ Yes ❑ No ADDITIONAL STAFF NAME ADDITIONAL STAFF EMAIL ADDRESS PHONE NUMBER (INCLUDE AREA CODE) FAX NUMBER (INCLUDE AREA CODE) CELLULAR PHONE NUMBER (INCLUDE AREA CODE) Section Six: Contractor Certification (DSHS staff enter on ACD Intake Detail as Intake Form Date) You must sign, date, and return this form. I certify, under penalty of perjury as provided by the laws of the State of Washington, that all of the foregoing statements are true and correct, and that I will notify DSHS of any changes in any statement. SIGNATURE DATE PRINTED NAME TITLE ATTACHED SUPPORTING DOCUMENTATION CHECKLIST ❑ Copy of your W-9 - Request or Taxpayer Identification Number and Certification ❑ Copy of statement showing non-profit 501(c) status (if applicable) ❑ List of partners, members, directors, officers, and board members (not applicable to sole proprietors) ❑ Copy of your Washington State Master Business License or proof of exemption ❑ List of any contracts you have had with the state that have been terminated for default, including a brief explanation (if applicable) ❑ List of Additional Addresses (if applicable) ❑ List of Additional Staff (if applicable) ❑ Copy of your Certificate of Insurance (if applicable) NEW CONTRACTOR INTAKE Page 4 of 4 DSHS 27-043 (REV. 04/2023)