ATTACHMENT E-Revised
Agency Business Organization Form
Agency Name: ______Date:______
Submitted by: ______Title:______
Agency Structure / Identify the legal structure and state of incorporation or registration, if applicable / Description:Evidence of authorization to do business in Nebraska / Check the type of organization of the applicant agency:
Governmental (County, State, City, or other governmental organization)
Non-profit/501(c)3
Other
If the agency marked “Other”; then the applicant must be currently registered with the Nebraska Secretary of State’s office to do business in Nebraska or agrees to register if applicant is awarded a subgrant.
WIC Local Agency Priority / Identify the priority of your agency in this application / ___1. A public or private nonprofit health agency that will provide ongoing, routine pediatric and obstetric care and administrative services.
___2. A public or private nonprofit health or human service agency that will enter into a written agreement with another agency for either ongoing, routine pediatric and obstetric care or administrative services.
___3. A public or private nonprofit health agency that will enter into a written agreement with private physicians licensed by the State, to provide ongoing, routine pediatric and obstetric care to a specific category of participants (women, infants or children).
___4. A public or private nonprofit human service agency that will enter into a written agreement with private physicians licensed by the State, to provide ongoing, routine pediatric and obstetric care.
___5. A public or private nonprofit health or human service agency that will provide ongoing, routine pediatric and obstetric care through referral to a health provider.
Organization History / History
Mission statement
Vision statement
Subgrant or Contract History with DHHS / Has your agency or contractor held a subgrant or contract with DHHS in the past 3 years? / No Yes (If yes, complete information below. Additional lines may be added.)
Subgrant or Contract:
Contact person(s):
Telephone:
Brief description:
Subgrant or Contract:
Contact person(s):
Telephone:
Brief description:
Subgrant or Contract:
Contact person(s):
Telephone:
Brief description:
Subgrant or Contract:
Contact person(s):
Telephone:
Brief description:
Subgrant or Contract:
Contact person(s):
Telephone:
Brief description:
Disclosure of Litigation* / Is there any litigation, administrative, or regulatory proceedings pending or threatened against your agency or contractor? / No Yes (If yes, complete information below)
Disclosure of Subgrant or Contract Termination*
(preceding 3 years) / Has your agency or contractor terminated a subgrant or contract? / No Yes (If yes, complete information below)
Has your agency or contractor had a subgrant or contract terminated? / No Yes (If yes, complete information below)
Subgrant or Contract:
Contact person(s):
Telephone:
Brief description of incident:
Subgrant or sontract:
Contact person(s):
Telephone:
Brief description of incident:
Subgrant or Contract:
Contact person(s):
Telephone:
Brief description of incident:
Disclosure of Contract Default*
(preceding 3 years) / Has your agency or contractor defaulted on contract? / No Yes (If yes, complete information below)
Contract or subcontract:
Contact person:
Telephone:
Brief description of incident:
Contract or subcontract:
Contact person:
Telephone:
Brief description of incident:
Contract or subcontract:
Contact person:
Telephone:
Brief description of incident:
*Failure to disclose such matters may result in rejection of the application or in termination of any subsequent subgrant. This is a continuing disclosure requirement. Any such matter commencing after submission of an application must be disclosed in a timely manner in a written statement to DHHS.
Audited Financial Statement /- Does the agency currently hold a contract with DHHS?
- Has the agency submitted audit reports (or operating statement if nonprofit organization) to DHHS for the preceding three year period?
- If agency responded “no” to either #1 or #2 above, provide an audited financial statement for the preceding three (3) year period as part of the application. Nonprofit corporations whose previous funding level has not required an audited financial statement shall submit a year end operating statement and balance sheet for the preceding three (3) year period and a current operating statement in lieu thereof.
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