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Appendices Checklist for:Four (4) New Jersey Youth Advisory Network (YAN) Regional Chapters Part I: Proposal FORMCHECKBOX Proposal Cover Sheet – (signed and dated)Use the RFP forms found directly under the Notices section on Website: dcf/providers/notices/Form: FORMCHECKBOX Table of Contents – Please number and label with page numbers if possible in the order as stated in Part I & Part II Appendices for paper copies, CD and electronic copies. FORMCHECKBOX Proposal Narrative in following order 25 pagesApplicant OrganizationProgram ApproachEvaluation, Reporting, and Quality ImprovementProgram Implementation Plan Part II: Appendices 1 FORMCHECKBOX Job descriptions of key personnel, resumes if available for key personnel (please do not provide home addresses or personal phone numbers. Include all educational and experiential requirements, salary ranges, if available. FORMCHECKBOX Staffing patterns including a proposed staff schedule FORMCHECKBOX Proposed Agency Organization Chart FORMCHECKBOX Proposed Program Implementation Schedule FORMCHECKBOX Any assessment tools that will be used in the program FORMCHECKBOX A sample Training, Coaching, and Technical Support Schedule (no more than 3 pages) shall be attached as an Appendix item and will not count towards the overall page limit FORMCHECKBOX Attestation Statement regarding collaboration and participation in evaluation activities FORMCHECKBOX Safe-Child Standards Description of your agency’s implementation of the standards (no more than 2 pages) FORMCHECKBOX DCF Exhibit D Budget Form and Budget Narrative FORMCHECKBOX Copy of agency’s Conflict of Interest policy FORMCHECKBOX Copies of any audits or reviews completed or in process by DCF or other State entities from 2014 to the present. If available, a corrective action plan should be provided and any other pertinent information that will explain or clarify the applicant’s position. If not applicable, include a written statement. FORMCHECKBOX Dated List of Names of Board of DirectorsTitles, Address and Terms FORMCHECKBOX Signed Standard Language Document (SLD) [Version: Rev. June 6, 2014] Form: FORMCHECKBOX Document showing Data Universal Numbering System (DUNS) Number [2006 Federal Accountability & Transparency Act (FFATA)]Website: Helpline: 1-866-705-5711 FORMCHECKBOX System for Award Management (SAM) printout (or Renewal) showing "active" status (free of charge).Website: Helpline: 1-866-606-8220 FORMCHECKBOX Applicable Consulting Contracts, Affiliation Agreements/Memoranda of Understanding related to this RFP. If not applicable, include a written statement FORMCHECKBOX Business Associate Agreement/HIPAA, with signature under Business Associate [Version: Rev. 9-2013] Form: FORMCHECKBOX Professional Licenses related to job responsibilities for this RFP.If not applicable, include a written statement FORMCHECKBOX Affirmative Action Certificate -or- Renewal Application [AA302] sent to TreasuryWebsite: : FORMCHECKBOX Certificate of IncorporationWebsite: FORMCHECKBOX For Profit: NJ Business Registration Certificate with the Division of Revenue. See instructions for applicability to your organization. Website: If not applicable, include a written statement. FORMCHECKBOX Agency By-laws FORMCHECKBOX Tax Exempt Certification Website: FORMCHECKBOX Disclosure of Investigations & Other Actions Involving Bidder Form (PDF) (signed and dated)Form: FORMCHECKBOX Disclosure of Investment Activities in Iran (PDF) (signed and dated)Form: FORMCHECKBOX For Profit: Statement of Bidder/Vendor Ownership Form (PDF) (signed and dated)See instructions for applicability to your organization. Form: not applicable, include a written statement FORMCHECKBOX Chapter 271** Signed and datedWebsite: : FORMCHECKBOX Source Disclosure Certification Form [P.L. 2005, c 92-formerly Executive Order 129] (signed and dated) Website: : FORMCHECKBOX For Profit: Two-Year Chapter 51/Executive Order 117 Vendor Certification -and- Disclosure of Political Contributions (signed and dated) [Version: Rev 4/17/15]. See instructions for applicability to your organization. Website: If not applicable, include a written statement. FORMCHECKBOX Annual Report to Secretary of StatePlease provide a copy of your filing confirmation and/or report. Website: FORMCHECKBOX Non Profit: Annual Report - Charitable Organizations Website: not applicable, include a written statement FORMCHECKBOX Certification Regarding Debarment-(Signed and dated)Form: FORMCHECKBOX Statement of Assurances – (Signed and dated)Use the RFP forms found directly under the Notices section: Website: dcf/providers/notices/Form: . FORMCHECKBOX Tax Forms: Non Profit Form 990 Return of Organization Exempt from Income Tax -or- For Profit Form 1120 US Corporation Income Tax Return 9. FORMCHECKBOX Most recent Audit or Financial Statement (certified by accountant or accounting firm) Audit: For agencies expending over $100,000 in combined Federal/State Awards -or-Financial Statement: For agencies expending under $100,000 Policy: ................
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