Fully executed program agreement

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-Jlo fi[1[ nr;:n'unr':; New Contractor lntake lnstructions All New DSHS Contractors must: . Complete, sign and submit the lntake Form to the Department of Social and Health Services (DSHS). . Register in the Statewide Payee Registration System. This system is maintained by the Washington State Department of Enterprise Services (DES) to process payments for all Washington state agencies. To register, follow the online instructions at https://ofm.wa.qov/it-svStems/accountinq-svstems/statewide-vendorpavee-services. You must complete this step in order to be paid. Please do not return this DSHS Contractor lntake Form to DES; they will not process it. All Existinq DSHS Contractors who have changed their business name or business organization, or experienced other significant changes, ggg!: r Update their information in the Statewide Payee Registration System by following the instructions at https:/iofm.wa.qov/it- svstems/accountinq-svstems/statewide-vendorpavee-services/changinq-your-vendor-reqistration. r Complete, sign and submit a new Contractor lntake form to the Department of Social and Health Services (DSHS). Section One: Contractor NamelBusiness Orqanization 1. Contractor name. r For an lndividual or Sole Proorietor, enter your name as shown on your Social Security card on the "Name" line. Sole Proprietors provide Last Name, First Name, Middle Name, and Suffix. . Other entities. Enter your business name as shown on the legal document creating the entity. 2. Business Organization. Please mark onlv one. " lf you are a nonresident alien foreiqn person or a business entity e he IRS may require you to complete Form W-8. r lf you are a Non-profit Corporation or a Faith-Based Non-Profit Corporation attach a copy of your 501(c) status. 3. Taxpayer ldentification Number (TlN). . lndividual or Sole Proprietor - lf you are a sole proprietor you may enter either your Social Security Number (SSN), or if you have one, your federal Employer ldentification Number (ElN). e Other Business Entities - Enter the entity's Employer ldentification Number (ElN). lf the entity does not have an ElN, enter the SSN of the owner of the business. . Resident alien. - lf you are a resident alien and you do not have and are noi eligible to get an SSN, your TIN is your IRS individualtaxpayer identification number (lTlN). Enter it in the SSN box. 4. Default Reported, Waiver Certification, Fiscal Year, UBI Number, Business License, and Unique Entity ldentifier (UEl) Number. . List any contracts that you have had with the state that have been terminated for default. . Certify whether you require your employees to sign mandatory individual arbitration clauses or class or collective action waivers. For more information review https://des.wa.qovlservices/traininq/contracts-procurement-traininq/workers-riqhts. . Provide your fiscal year end date. . Provide your Washington State Uniform Business ldentifier (UBl) Number. . Attach a copv of vour State Master Business License. You may be exempt from registering with the State of Washington under certain circumstances. For more information review: http://bls.dor,wa"qov/faqlicense.aspx . Provide your Unique Entity ldentifier (UEl) Number. Section Two: Contractor Primarv Address Enter the primary address information of your business. lf this form is for a new DSHS contract, and you want to provide a contract-specific address in addition to your primary one, please do so in Section Five. Section Three: Contractor Ownership Check those that, in your opinion, apply to your organization. Please provide a certification number,ifavailable. Forthedefinitionofmicrobusiness,minibusinessandsmall business,seeRCW39.26.010(16),(17)and(22). Section Four: Contractor Contact Person(s) Enter the primary contact information, and job title, for your business. lf you are completing this form for a new DSHS contract, and you want to provide a contraclspecific contact person other than your primary one, please do so in Section Five. Section Five: Additional lnformation 1. Contractor Additional Addresses. lf applicable, provide additional addresses used for DSHS Contracts. 2. Contractor Additional Staff. lf applicable, provide additional staff information for DSHS Contracts. Additional staff may include those who have authority to sign a DSHS contract on behalf of the business, and are referred to as a signatory. Section Six: Contractor Certification You must sign, date, and return this form before DSHS will issue a contract. NEW CONTMCTOR INTAKE DSHS 27-043 (REV. 04/2023) Page 1 of4