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SIGNATURE DATE <br />I certify, under penalty of periury as provided by the laws of the State of Washington, that all of the foregoing <br />statements are true and correct, and that I will notify DSHS of any changes in any statement. <br />You must sign, date, and return this form. <br />Section Six: Contractor Gertification (DSHS staff enter on ACD lntake Detail as lntake Form Date) <br />PHONE NUMBER (tNCLUDE AREA CODE) <br />() <br />ADDITIONAL STAFF NAME <br />tr ves <br />tr ves <br />(DSHS staff enter as applicable on ACD) <br />Additionalstaff person is a(n): <br />n Officer or Board Member I Partner n Staf Member tr Elected Official <br />I Otfrer (please identify) <br />nruo <br />Iruo <br />ls the additional staff authorized to sign contracts? <br />ls the additional staff a contact for DSHS contracts? <br />PHONE NUMBER (INCLUDE AREA CODE) <br />() <br />ADDITIONAL STAFF NAME AND TITLE <br />2. ADDITIONAL STAFF: lF YOU HAVE MORE THAN TWO ADDITIONAL STAFF (LISTED BELOW, WHO ARE ALSO RELEVANT TO YOUR <br />DSHS CONTRACTS, PLEASE PROVIDE INFORMATION ABOUT THOSE STAFF ON A SEPAMTE PAGE. <br />Additional staff person is a(n): <br />E Officer or Board Member n Partner I Staf Member n Elected Official <br />fl Otfrer (please identify)(DSHS staff enter as applicable on ACD) <br />ls the additional staff authorized to sign contracts? <br />ls the additional staff a contact for DSHS contracts? <br />n Yes <br />n ves <br />nruo <br />[ruo <br />FAX NUMBER (INCLUDE AREA CODE) <br />() <br />CELLULAR PHONE NUMBER (TNCLUDE AREA CODE) <br />() <br />FAX NUMBER (INCLUDE AREA CODE) <br />() <br />TITLE <br />PRINTED NAME <br />ADDITIONAL STAFF EMAIL ADDRESS <br />ADDITIONAL STAFF EMAIL ADDRESS <br />CELLULAR PHONE NUMBER (INCLUDE AREA CODE) <br />() <br />ATTACHED SUPPORTING DOCUMENTATION CHECKLIST <br />f] Copy of your W-9 - Request or Taxpayer ldentification Number and Certification <br />tr Copy of statement showing non-profit 501(c) status (if applicable) <br />I tist of partners, members, directors, officers, and board members (not applicable to sole proprietors) <br />I Copy of your Washington State Master Business License or proof of exemption <br />I tist of any contracts you have had with the state that have been terminated for default, including a brief <br />explanation (if applicable) <br />f t-ist of Additional Addresses (if applicable) <br />I List of Additional Staff (if applicable) <br />I Copy of your Certificate of lnsurance (if applicable) <br />NEW CONTRACTOR INTAKE <br />DSHS 27-043 (REV. 0412023) <br />Page 4 of 4