Provider Information Summary Form- Grants FY24

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.

Definitions:

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 emails the 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.

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

1. Organizational, and if applicable, Board Charts
2. Policies and procedures related to time reporting
3. Policies and procedures related to purchasing
4. Policies and procedures related to accounts payable
5. Policies and procedures related to account receivable
6. Policies and procedures related to conflict of interest
7. Organization’s salary/indirect cost allocation plan
8. Organization’s last single audit, if applicable
9. Organization’s W-9 - must be hand-signed and dated within the last 3 months. Current State guidelines do not permit electronically signed W-9s.
10. Insurance Certificate - Policies must be currently active.  You can request a copy of Attachment C from ahs.vdhdsuprovidersummary@vermont.gov.
11. Indirect Rate Letter - only if you have a federally negotiated indirect rate