Required Contract Documents

Please use this form to identify documentation needed to process your contract.
Please complete and return document and certifications below to your Program Manager and Contract Liaison
Documents may be scanned and emailed.  Mailed documents should sent to the attention of:

Your Program Manager
Chicago Department of Public Health
DePaul Center Room 200 Conference Room 2113
Budgets must be submitted in excel.

 

Document Name Document Description Form/Certification Link Requirements for Original Award Requirements for Release of funds Under an Existing Award Budget Revisions Requirements for Amendments to existing Contracts, as applicable
Direct Deposit Form Completing this form allows the City to deposit checks directly into the account designated. Please print form, complete, sign and return Direct Deposit Form

 

 

(only if changed from initial submittal) 

 

(only if changed from initial submittal)

 (only if changed from initial submittal)

 

Bank Depository Authorization Form Completing this form allows the City to deposit checks directly into the account designated. Please print form, complete, sign and return. Bank Depository Fillable Form   

 

(only if changed from initial submittal)

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(only if changed from initial submittal)

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(only if changed from initial submittal) 

Signature Authorization This document who in your agency is authorized to sign reimbursement vouchers and related documentation.  Please print form, complete, sign and return.  Signature Authorization Fillable

 

 

 

(only if changed from initial submittal)

 

 

Insurance Certification Insurance requirements: Please print form, complete, sign, and return. A new form is needed when insurance expires. The city will not pay vouchers if insurance on file has expired.

Insurance Certificate of coverage

 

 

 

 

(only if expired)

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Budget Form Budget Instructions 2020 Budget Form  √   √ 

 

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Scope of Services or Work Plan Please contact your CDPH program manager for Scope and/or Work Plan requirements. Scopes must be signed by both parties    

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(only if changed from initial submittal)

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(only if changed from initial submittal)

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(only if changed from initial submittal) 

Certificate of Good Standing with the IRS If your organization is not found on this website, contact local IRS office to check your IRS status and ensure your organization is included. Please print and submit certificate.  

https://goo.gl/KKGt6r

 

 

(only if changed from initial submittal)

 

 

CCR or Sam Certificate Please access the link.  If necessary, please contact and coordinate with website administrator/Service Desk URL directly (http://www.FSD.gov) to check your SAM entity registration status and ensure your organization is included in this website.  Please print and submit certification.

SAM Link -

https://goo.gl/Xx1tD

 

(only if changed from initial submittal)

 

 

Certificate of Good Standing with the State of Illinois Please provide a copy of State Good Standing report. The state link and a sample of the certification required are attached. Please print and submit certification 

https://goo.gl/32L5Dj

 

(only if changed from initial submittal)

 

 

Economic Disclosure Statement with City (EDS) Please provide a copy of the EDS statement. The link to request a copy and a sample of the certification required are attached. Please print and submit certification.

https://goo.gl/9dfGjd

 

(only if changed from initial submittal)

(only if changed from initial submittal)

 

 

Contract Service Site Form
Please complete this form as it relates to your grant. The form is pdf fillable and can be emailed to your CDPH contact.
Delegate Agency Resource Fillable Form        
             

 

 Supporting Information Facts

 I Want To