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#Hr <br />/;r,i/"rji. Sr,r, <br />Depailnenl of Sociil <br />& Herllh senices <br />Tenslo.ming li,/es <br />NEW CONTRACTOR INTAKE <br />DSHS 27-043 (REV. 04/2023) <br />New Contractor lntake <br />PHONE NUMBER (INCLUDE AREA CODE) <br />() <br />EMAIL ADDRESS COUNTY WHERE PRIMARY ADDRESS IS (FOR OUT.OF-STATE CONTMCTORS) <br />CITY, STATE, AND ZIP CODE <br />CONTRACTOR PRIMARY ADDRESS (NUMBER, STREET, AND APARTMENT OR SUITE NUMBER) <br />Section Two: Contractor Primary Address (DSHS staff enter on ACD lntake Detail screen) <br />4. DEFAULT REPORTED, DETERMINATION OF CONTMCTOR STATUS, WAIVER CERTIFICATION, FISCAL YEAR, UBI NUMBER, BUSINESS <br />LICENSE, AND UEI NUMBER <br />Have you had any contract with the state terminated for default? <br />f, Yes I tto <br />lf yes, attach a list of terminated contracts with an explanation why each contract was terminated. <br />Are you or any member of your staff a current employee of DSHS? <br />I Yes I t'lo <br />lf yes, attach a brief explanation describing you or your employees duties as a DSHS employee. <br />Does your business require its employees to sign or agree to, as a condition of employment, mandatory individual <br />arbitration clauses or class or collective action waivers?IYes nruo <br />lsy <br />T <br />our fiscal <br />Yes <br />ear end the same as the calendar year (January 1 through December 31)? <br />No <br />lf the answer is no, what is your fiscal year end date? _ <br />What is your Washington State Uniform Business ldentifier (UBl) Number? _ (Enter all 9 numbers, No DASHES) <br />Attach a copy of your current Washington State Master Business License or explain below why you are exempt from <br />registering your business with the State of Washington. (See page 1 for information on exemptions.) <br />What is your Unique Entity ldentifier (UEl) number? (Enter all numbers, NO DASHES) <br />3, TMPAYER IDENTIFICATION NUMBER (TIN) <br />Enter your TIN in the appropriate box. <br />. For individuals, this may be your Social Security Number <br />(ssN). <br />. For other entities, it is your Employer ldentification Number <br />2. BUSINESS ORGANIZATION <br />! tndividual or Sole Proprietor I General Partnership <br />n Non-Profit Corporation (Attach a copv of 501(c) status) X timiteO Liability Partnership (LLP) <br />I for profit Corporation n timiteO Liability Limited Partnership (LLLP) <br />I faitfr Based (FBO) Non-Profit Corporation n timiteC Liability Company, filing as a Corporation <br />n fattn Based (FBO) Unincorporated I LimiteO Liability Company, filing as a Partnership <br />n Governmentat Entity f, timiteO Liability Company, filing as a Sole Proprietor <br />I Foreign Person or Entity <br />lf your business is NOT a sole proprietorship, <br />attach a list of the partners, members, directors, officers, and board members. <br />1. CONTRACTOR NAME DBA OR FACILITY NAME <br />Section One: Contractor Name/Business Organization (DSHS staff enter on ACD lntake Detail screen) <br />FAX NUMBER (INCLUDE AREA CODE) <br />() <br />SocialSecurity Number <br />OR <br />Employer ldentification <br />Number <br />(Enter all 9 numbers <br />NO DASHES) <br />(Enter all 9 numbers, <br />NO DASHES) <br />Page 2 of 4