Contractor Information Update

Every box with a red asterisk must be answered, the form will not be able to be submitted if there is no information within that box.

Contractor Name

As shown on your current DCYF Contract(s).

Contractor Name Change

Has your name changed from your last renewal?

Yes

Business Organization

Please select one.

Unified Business Identifier (UBI)

Has your EIN or SSN Changed?

Since your last Contract renewal with DCYF.

Yes

Fiscal Year End

Fiscal year-end refers to the completion of a one-year, or 12-month, accounting period.

mm/dd/yyyy

Contracts Terminated for Default

Have you had any Contracts with Washington State that have been terminated for cause (failed or refused to perform contractual obligations and breached the contract, for example).

Yes

Primary Contract Contact Name

Primary Contact Person for this Contract is a(n):

Primary Contract Contact Email

Primary Contract Contact Phone Number

Phone

Primary Contact Phone Type

Cell

Landline

Additional Primary Contact Phone Number?

Yes

Primary Address for Contract

Please enter (Number, Street, Suite) and (City, State, and Zip code).

Additional Address?

Do you have an additional address for billing and/or mailing that we need to know for sending invoices or written communication.

Billing

Facility

Mailing

Primary Contact is same person as Contract Signer?

Yes

Is Primary Contact the same for Service Referrals?

Yes

Contractor Ownership Type

In your opinion, do you consider your business to be one or more of the following? If so, please check the box(s) that apply.

DCYF Contact

Please select the DCYF Contact as shown on page 1 of your Contract your renewing or the DCYF contact that you received the renewal email from.

Contracted Services

Please select the Contracted services that were identified in your email from DCYF for renewal.

Additional Insurances

Do you accept additional Insurances?

Yes

Contractor Certification

I certify, under penalty of perjury as provided by the laws of the State of Washington, that all of the foregoing statements are true and correct, and that I will notify DCYF of any changes in any statement. Please print your name and tile below.

Form Date Field

Select todays date.

File Upload

Please upload the following documents for the Contracted Services you selected in this form that you are renewing:

Excel staff list for each Contracted Services
Updated Insurance COI and Policy, if it has or is expiring by July 31st.

Drop your files here

Send me a copy of my responses

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