CHICAGO DEPARTMENT OF FAMILY & SUPPORT SERVICES

DELEGATE / PARTNER AGENCY AMENDMENT PACKAGE (INCLUDING ARRA)

CHECKLIST

Agency Name: ______PO #: ______Release #s: ____ _

Please complete and submit an original and one copy of the amendment package for your Purchase Order. Check-off, affix initials next to each fulfilled item and return the checklist as a cover for your completed forms to DFSS on Roundtable Submission date (to be provided, as applicable), Goldblatt Building, Department of Family and Support Services, 1615 W. Chicago Ave., 4th Floor West (Unless otherwise notified), Attn: Contracts Unit – Contracts Liaison (to be provided). Failure to submit the following forms/documents in accordance with DFSS instructions will delay the execution of your agency’s amendment.

1) Budgetary Documents (To be completed per instructions) 

2)  Signature Items

Amendment to Delegate Agency Grant Agreement (ARRA) or Amendment to
Grant Agreement (ARRA) pages (as applicable)

·  Completed, signed by Executive Director / Corporate President, and notarized  

Agency Signature Authorization form (New form(s) to be completed. Be certain

to complete upper right-hand portion of document also)

·  “Authorized Person’s Signature” – i.e., agency individual(s)

authorized to sign-off on agency vouchers and related documentation 

·  “Approving Person’s Signature” – i.e., agency representative

authorized to sign-off on agency agreements/amendments, who has

a higher ranking within the organization than the “Authorized Person” 

Note: An original and one copy of this form needs to be submitted

Bank Depository Authorization & Direct Deposit Vendor Payment Program (New forms

are to be completed. Be certain to complete upper right-hand portion of documents also)

·  New Bank Depository form to be completed per instructions including original signatures

by authorized official and countersigned by bank official, as appropriate 

·  Bank Name, Routing Number, Account Number, etc., is to be consistent with

Request for Advance information, as applicable 

·  An original Direct Deposit Vendor Payment Program form is to be submitted

including an original unsigned voided check 

Note: If your agency currently does not have Direct Deposit but wants to request it, complete

the Direct Deposit Vendor Payment Program form per instructions

Insurance Certificate of Coverage (Please make sure that your insurance is up to date)

Original to be submitted directly to City Comptroller’s Office, Federal

Funds Insurance Unit, 33 N. LaSalle St., Rm. 800, Chicago, Il., 60602,

Attn: Maria Santiago & separate copies directly to DFSS 