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Provider Information Summary Form- Grants FY23


The purpose of filling out this form is to provide the Vermont Department of Health, Division of Substance Use Programs the information and documentation needed to issue grants.


Fiscal Agent/Subrecipient: The Fiscal Agent is the name of your organization/ business name. The fiscal agent will directly receive grant funding and is responsible for managing the funds.  The Vermont Department of Health's Business Office mails or emails grant document, for review and signature, and sends the executed grant to the Fiscal Agent. Checks/electronic deposits will be issued to the Fiscal Agent listed on this form.

Program/Organization: This is the program/organization that provides the services outlined in the grant. The program does not receive funds directly from the state.

In order to complete this summary, you will need to have the following documents prepared to submit:

1. W-9 - Must be hand-signed and dated within the last 3 months. Current State guidelines do not permit electronically signed W-9s.
2. Insurance Certificate - Policies must be currently active.  You can request a copy of Attachment C from
3. Indirect Rate Letter - ONLY if you have a federally negotiated indirect rate

***After you finish the 1st page of this form, you'll have the option to hit "Save and Continue". This button will be located at the top right of each page (after the 1st page). If you choose save and continue, it will ask you for your email. The email you provide will receive an "edit link" which allows you to return to the form and continue where you left off. You can do this as many times as needed to complete the form. ***