DEPARTMENT OF HUMAN SERVICES
DIVISION OF FAMILY DEVELOPMENT
CONTRACT ADMINISTRATION
CONTRACT AWARD or RENEWAL PACKAGE
REFUGEE SOCIAL SERVICE PROGRAM

Program Summary
Contract Renewal Package
Contract Summary Sheet
Authorized Signatures
Service Delivery Information
Program Narrative
Index of Required Contract Documents
Contract Checklist
Document Verification Sheet (DVS)
Executive Order 129
Certification of Suspension and Debarment
List of Contracts/Grants
Contract Forms (List of Required Documents Available on DFD Website)

Instructions
Program Summary
Enter the information on the site where services for this program are provided.
Contract Summary Sheet
Enter Agency Name, Address, Telephone and Contract No.
, Federal Identification
No., Contract effective dates (as noted in the DFD contract award letter) and contract ceiling (per Annex B).
Enter CEO and Agency notice information. All data must be completed.
Authorized Signatories
Enter Authorized Signatory for the Contract (as authorized by Agency Bylaws or Board
Resolution).
IMPORTANT - This is the address where the signed contract and all relevant legal correspondence will be mailed – so please ensure this is the accurate address.
Service Delivery Information
Service will be provided as follows for each day of the week, enter the hours the agency will provide contracted services. Please indicate if there is a difference among any of the contracted services in the program specific narrative.
Emergency Provisions Describe any special arrangements which have been made to handle emergencies, e.g. voice mail instructions, special telephone numbers etc.
Service will not be provided on the following occasions List the occasions and dates when service will not be provided, e.g. December 25-Christmas, July 4-Independence
Day, etc.
Program Narrative
*Please see specific instructions attached to this section

ANNEX A - Program Summary
Program Name:
Site Address:
City, State, and Zip
Site Phone Number: - -
Program Director/Coordinator
Telephone #: - -
Fax: - -
E-Mail:

STATE OF NEW JERSEY - DIVISION OF FAMILY DEVELOPMENT
ANNEX A – CONTRACT SUMMARY SHEET
Provider Agency
Mailing Address
Telephone Number
Provider Agency Fiscal Year End
- -
Contract Effective Date to
Contract #
Federal ID
#
Contract Ceiling $
Organization Type County
Municipal (i.e. School)
% Indicate % of profit charged towards contract
Private, Non-Profit
Private, For-Profit
Faith-Based
Hospital-Based
Chief Executive Officer
Title
Mailing Address
Telephone Number - -
Fax Number
E-Mail Address
- -
All routine notices relevant to the administration of the program should be sent to:
Name & Title
Mailing Address
Telephone Number - -
Fax Number - -
E-Mail Address
Do you currently receive payment by Automatic Deposit (ACH) for this contract?
Yes No

Division of Family Development
Annex A
Authorized Signatures
List names and positions of persons authorized to sign the following and number of persons required to sign each transaction.
Name/Address Position
# of Signatures
Required
1
Contract
2
3
1
1
Financial Reports
3
Contract 1
Checks
3
1
2
3
1
1
Agreements
2
3
Note 1 - Enter Authorized Signatory for the Contract (as authorized by Agency Bylaws or Board
Resolution). This is the address where the signed contract and all relevant legal correspondence will be mailed. This should be the individual who signs the SLD (page
23). This may not be the same individual as noted in the Annex A summary sheet. In the event of emergency notification, please include e-mail and fax number.
Contract Signatory
Title
Mailing Address
Telephone Number
Fax Number
E-Mail Address
- -
- -

Division of Family Development
Annex A
Service Delivery Information
Contract #
Program Name:
Site Address:
City, State, and Zip
Site Phone Number: - -
Program Director/Coordinator
Telephone #: - -
Fax: - -
E-Mail:
Service will be provided as follows (designate time):
Sunday
From
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Services will not be provided on the following occasions:
Date (s) Occasion
To

Division of Family Development
ANNEX A
PROGRAM OPERATIONS NARRATIVE
REFUGEE SOCIAL SERVICES PROGRAM
ANNEX A
PROGRAM GOALS AND DESCRIPTION
The Department of Human Services (DHS) Division of Family Development (DFD) recognizes that critical social services and supports are needed for new refugee arrivals and eligible populations resettling in New Jersey to help them transition to their new life. Refugee Social
Services (RSS) under the Office of Refugee and Resettlement Program (ORR) is 100% federally funded, under Part 400 of Title 45 under the Code of Federal Regulations (CFR) to provide an array of employability and supportive services that foster personal responsibility, promote economic self-sufficiency and social adjustment.
Categories of Refugees and Eligible Immigration Status for ORR services:

Refugees in possession of an I-94 stamped “Admitted as a Refugee Pursuant to Section
207 of the Act” are eligible for services;

Parolees who have an I-94 with “paroled as a refugee” or “207” stamped or written on the document are eligible;

Cuban/Haitian entrants who have been granted parole, applied for asylum, or are in exclusion or deportation proceedings but have not received a final order of deportation;

Asylees;

Special Immigrant Visas (SIVs) from Iraqi and Afghan; and

Certified Victims of Trafficking.
The primary purpose of New Jersey’s RSS is to assist eligible populations to adjust socially and attain the skills needed to find employment and becoming self-sufficient as quickly as possible through an array of services. These services are provided in collaboration with a network of service providers to ensure that the necessary support and assistance is given in accordance with
ORR’s priority in providing services.
Priority in Providing Services

All newly arriving refugees during their first year in the U.S. who apply for services;

Refugees who are receiving cash assistance;

Unemployed refugees who are not receiving cash assistance;

Employed refugees in need of services to retain employment, achieve job upgrades, or attain economic independence.
Services Available and Time Limits

Providers should consider the strengths, resources, and community capacity to ensure that refugees access the highest quality of services within their community. These services are an important aspect of helping refugees integrate and become contributing members of their communities as quickly as possible.
The Division believes that successful resettlement requires a continuum of support and services of State and local government, public and private partners, community-based agencies, and refugee resettlement agencies. DFD strives to provide a comprehensive approach to the RSS program through a network of culturally competent providers and resettlement agencies, local community resources, and supportive social services through the County Welfare Agencies
(CWAs) and employment services, such as the One Stop Career Centers (OSCCs) to foster social and economic self-sufficiency as soon as possible.
Description of Possible Services as indicated in 45 CFR 400.154
Employment Services – must include an Individual Employment Plan (IEP) and Family Self
Sufficiency Plan (FSSP ) to determine the appropriate skills, training and services necessary to help the individual or family become self-sufficient through timely employment. Examples of services include:
1.
Employment Assessment Services – adjunct services (aptitude for certain professions, skills testing, job coaching and development).
2.
Job search, placement, and follow-up.
3.
On the job training – provided by prospective employers with expected outcome of employment.
4.
Vocational Training – that provide ready skills in a short period of time and part of the
IEP and FSSP plans a.
Tuition reimbursement –available for vocational training, skills certification, licenses, etc. upon DFD’s approval.
5.
Skills Certification – recertification of licenses; except for certain restrictions – must meet the criteria for appropriate training in 45 CFR 400.81(b).
6.
English language instruction – with emphasis on formal and certified instruction, and as it relates to obtaining and retaining a job – no other resources available a.
ESL – details of type and services – certified, schedule, duration
(ESL and vocational training must be provided to the fullest extent feasible outside normal working hours to avoid employment interference).
7.
Transportation – when necessary for employability services or for acceptance or retention of employment – no other resources available.
8.
Translation and interpreter services, when necessary in connection with employment or participation in an employability service.
9.
Case Management Services – as defined as the determination of specific service(s) to which to refer a refugee in accordance with an employability plan, referral to such service(s), and tracking of the refugee’s participation in such services employable.
10.
Other Service – for example, information and referral services, (these were previously mentioned above).
11.
Social Adjustment Services – household budget & management, health related services, short-term counseling (crisis).

The employment-related descriptions listed above are specific eligible social service activities for the purpose of obtaining gainful employment in accordance with ORR guidelines. For all individuals accessing services under this grant, individuals must be given every opportunity to quickly access services and supports to assist them in becoming integrated members of American society and employed and to become self-sufficient. In addition, they should not be duplicative of existing service delivery systems.
Though social services are up to 60 months, as established by 45CFR 400.152, priority for providers should be for those that have been in New Jersey for less than 12 months.
Learning English is a very critical and primary component of obtaining employment. Instruction can take place in a wide range of settings which must be considered when referring or providing these services to ensure that individual needs and varying schedules are being met. If certified and flexible ESL services are offered in the community, individuals should be informed of those services to consider meeting the schedules of the families.
Another important component of the ORR program is refugees easily accessing culturally and linguistically supportive social services. The resettlement agencies are required to refer individuals to the CWA to obtain federally funded benefits and services, such as medical, food and if eligible, cash assistance to assist them in becoming integrated into their new society. This is in an effort to meet their basic needs while emphasizing self-sufficiency. The referral process will ensure expedited services to these appropriate and critical benefits.
Likewise, the CWA also will refer eligible individuals that need culturally and linguistic ORR employability social services; such as cultural orientation, job readiness, preparation and placement, as well as, supportive and ESL services to the local resettlement agencies.
The resettlement agency contracted with DFD must provide those prescribed employability services as outlined above in accordance with ORR’s regulatory provisions at 45 CFR 400.154.
MONITORING AND QUALITY ASSURANCE
1.
DFD will conduct a minimum of two annual site and chart reviews.
2.
DFD will conduct unannounced site and chart reviews.
3.
The State refugee coordinator should be informed, or made aware of, critical or unusual events (such as criminal or federal investigation); all monitoring/site visits from ORR and/or the national agency and a copy of that agency’s final report; budget and/or funding reductions; staffing changes and/or other changes or events which could affect your agency’s operations or could cause concerns and/or problems to the community and/or the State of
New Jersey.
Administrative General Requirements

Participate in collaborative meetings and committees with key partners related to the scope of work outlined in this contract.

Employ adequate qualified and bilingual staff to meet the performance requirements or deliverables of the contract.


Develop and utilize sound fiscal and programmatic accountability procedures and policies, which are approved by DHS/DFD.

Train staff on confidentiality practices and implement policies to safeguard confidential and private information.

Maintain accurate and current client information in accordance with State and Federal recording requirements.

Identify disaster recovery protocol and procedures for shifting services in the event of extreme circumstances, such as a natural disaster or significant damage to the service location, and provide a detailed Business Continuity and Disaster Recovery Plan that will be implemented in the event of an emergency.

Conduct an annual self-assessment and evaluation to ensure that program services are informed by research, best practices and to measure the impacts of service delivery on programs and clients.

Establish a process to extract and analyze data.
Key Statutory and Regulatory Requirements under this contract:
The provider agency assures that it will comply with required statutory requirements and ensure
Federal and State funds are utilized for eligible clients and services in accord with DHS/DFD policies and regulations. At a minimum, the agency will: a.
Have internal controls and performance measures to determine whether the rules are accurately applied; b.
Adhere to applicable Federal rules and State program compliance requirements; and c.
Assure appropriate use of funds for allowable services to carry out the goals and objectives of the program.
Eligible Clients
In accordance with program funding requirements – only clients that meet program eligibility criteria should receive services. The provider agency is required to maintain a system of internal control and appropriate processes to ensure the integrity of program funding.
Personnel Requirements
The agency director or program designee must attend and participate in DFD-sponsored inperson meetings and trainings, or conference calls as directed by the DFD Program Staff.
Fiscal Standards and Accountability
Recipients and sub-recipients of Federal and State funds are responsible for the proper use of such fund. Simply, this means that the funds are used for the intended purpose with compliance with all Federal, State and contract regulations. All parties are responsible for the transparency and accountability for the funds and are subject to administrative, contractual and legal sanctions for the misuse and/or improper use of these funds. Provider Agencies are considered subgrantee/recipients under this contract and are subject to Federal laws, regulations and provisions of this contract as set forth in this document; and must ensure adherence to all applicable regulations, including: a) Contract funds are allocated to meet program objectives and for the purpose as intended.

b) Fiscal and accounting procedures are sufficient to permit the preparation of required reports and the proper reconciliation of expenditures to adequate source documentation to establish funds have been used appropriately for the intended purpose in accordance with all applicable laws, regulations, and contract cost principles. a.
Annual completion of the Single Audit, as required. b.
Funds are not used to support inherently religious activities, such as religious instruction or activities. c.
Funds are not used to support lobbying activities to influence proposed or pending
Federal or State legislation or appropriations. d.
Funds are expended in accordance with all pertinent laws and regulations.
Allowable Cost
The determination of allowable costs is defined in the Standard Language Document
(SLD), RFP, DHS and DFD Cost Reimbursement Manual (CRM) and the DHS
Contract Policy and Information Manual (CPIM). Expenditures are defined as those costs which are restricted to activities related to programmed plan development; complaint files management; public hearing information; program monitoring and coordination; report preparation; evaluation of program outcomes; personnel management; travel; equipment; supplies; audits and response management; and indirect costs such as maintenance of facilities, utilities, and general management staff.
General Program Requirements
The use of State and Federal funds must adhere to all governing laws and regulations including those contained in the: i.
New Jersey regulations. ii.
DHS/DFD Contract terms contained in the SLD and RFP. iii.
DHS/DFD contract rules and regulations contained in the CRM and
CPIM. iv.
DFD instructions and guidance memos, including all approved amendments or revisions. v.
All other Federal, State and local laws and regulations.
The agency must meet all contract expectations as described in the RFP as well as those detailed in this contract. Failure to meet any performance standard and contract expectations can be grounds for revision of the contract whereby current funding is reduced, contract is suspended or terminated and can affect future consideration for funding.
In addition to the core areas of program delivery, provider agencies must maintain administrative and fiscal accountability, meet reporting requirements, and ensure program integrity to meet all program compliance and performance standards. As recipients of government funds, all agencies must adhere to all Federal and State laws and regulations as stated above.
DFD PROGRAM AND FISCAL REPORTS
The goal of program reports is to use data to improve program services, service delivery and utilization. Monthly, Quarterly and Annual Reports may include but not be limited to:
1.
Monthly and Quarterly reports on every client serviced is required and should include but not be limited to:

a.
Federally required reports (monthly, trimester and a the Annual Goal Plan) b.
DFD required reports:
1. Arrival data i.
2. Asylees data ii.
3. Number of clients serviced iii.
4. Number of employment placements unduplicated
2.
Other program reports as requested by DFD in the timeframe required.
All program reports should be submitted to Renee Ingram at renee.ingram@dhs.state.nj.us
Fiscal Reporting Requirements
The agency is required to submit program and fiscal reports within the required timeframes. At a minimum, the following reports are required:
Fiscal reporting is required on a quarterly basis combining subcontracted and direct agency expenditures. Actual expenditures must be reported using the Annex B form on a cumulative basis by the 20th day of the following month after the close of each calendar quarter.
The Final Report of Expenditures (ROE) is due 120 days after the contract period ends.
The expenditure reports must contain an original signature of the CEO and fiscal officer designated by the agency for this program.
An initial advance payment will be issued when the contract is fully executed. Future quarterly reimbursements will occur subsequent to DFD’s receipt and review of the expenditure report for the previous quarter and as long as all other contract deliverables are met.
All reports are to be sent to:
DFD, Office of Contract Administration
P.O. Box 716
Trenton, New Jersey 08625-0716
Attention: Contract Fiscal Unit
Payment Terms
The initial advance payment representing 25% of the contract ceiling will be issued when the contract is approved and signed. Subsequent quarterly advance payments are issued upon receipt and review of the quarterly ROE and, assuming all other contract obligations are current and there are no violations of any other contract provisions. Adjustments to a quarterly payment may be made for a variety of reasons, including provider agency spending patterns, DFD fiscal review issues, audit matters that come to our attention, or as needed to meet program delivery and DFD
Budget/ Fiscal issues.

Annex A - Narrative and Questions
A.
Narrative
Please provide a detailed written narrative of your agency’s proposed program. The program description should present a clear picture of the program’s structure, staffing, description and implementation of specific services to be provided (as detailed in the Annex A scope of work) and service delivery methods/process, referral process if applicable, coordination with other collaborators/stakeholders and local service providers as applicable. The agency’s description should explain how and where the services will be provided and by whom – detailing the use of all consultants and subcontractors with details of the agency’s monitoring of the services from consultant and subcontractors.
The narrative should include a detailed implementation plan for the completion of the DFD program including all components detailed in the scope of work.
B.
Annex A Questions
Please concisely respond to the questions below:
1.
Staffing: Describe staff positions, responsibilities and provide staffing structure information. (Provide their position, titles, duties, and the percentage of time worked in the program). a.
If staff time is charged to more than one program and/or grant, describe the process used to ensure the allocation of time spent on each program/grant is correct or supported. b.
Who supervises the provision of services/activities/outcomes and ensures they are timely, documented and reported? c.
What kind of staff in-service training do you provide to the program staff? d.
Will any services be provided by consultants or subcontractors? If so, please provide details of the consultant/subcontractor (i.e. scope of work, terms of the agreement, reimbursement terms, key staff including areas of expertise and credentials). Copies of the agreement must be attached or contract approval will be delayed.
2.
Provide a brief overview of your agency’s program and specific role with administering the ORR program. The narrative should include: a.
Your agency’s success and/or challenges administering the program last year. b.
Provide statistics of how many clients were served through ORR funds – and the services provided – indicate the types of populations serviced. c.
Explain the goals and objectives for this contract period. d.
Describe the need for the grant and how it is going to be utilized. e.
Indicate other Federal, match dollars and amount, etc.; used for the same or similar services and/or populations. f.
Describe what employability services your agency will provide. Include the following: i.
Type of employability services, as outlined above. ii.
If ESL is provided, please provide details – (certified instructors, type of instruction basic, structured, classroom or home setting; on-site or referred, various levels, number of hours per week, how many instructors, language spoken etc.).

g.
Description of how you will ensure that the prioritized populations are being serviced. Priority is for new arrivals and the unemployable – within the first year of arrival. h.
Explain your referral process with the CWA and other community resources and collaboration efforts. Accessing supportive social services is paramount due to the urgent need to obtain basic services. i.
Provide details of your staffing composition – experience and language, percentage of time allocated under this contract, and projected staff to client ratio.
Cultural and linguistically competent staff is essential due to the language and social barriers many of the populations face.
3.
Describe how your internal process and monitoring procedures ensure that refugees do not receive duplicated services if they are eligible for services under more than one grant.
4.
Describe how your agency plans to evaluate the program. Explain how your agency plans to collect data. Identify any strengths and weaknesses from prior evaluations.
5.
Explain the monitoring and quality assurance of the program including: a.
Submit a copy of the Agency’s Quality Assurance and Monitoring Policies and
Procedures. b.
Provide information on refugee’s satisfaction survey for program services. How often is this survey done? If your agency does not have a customer survey, please describe your plan to implement one. c.
Does the agency have a wait list for any services? If yes, how does the agency determine which refugees receive services and when?
6.
What systems are in place to ensure that accurate records are maintained for completing all required program and fiscal reports?
7.
How does your agency provide linguistically and culturally appropriate services to clients? Provide information on your program staff’s multi-lingual capacity (languages, cultural and translation services). a.
How does your program ensure compliance with Title VI (LEP policy)? Are program forms, flyers and other written materials translated into client’s native language? Do clients sign forms indicating their understanding of the program requirements and services? How is this issue addressed with illiterate clients? b.
Describe your agency’s English language and literacy services.
8.
What barriers or challenges do you anticipate in the implementation of the program goals, objectives, activities and achieving its outcomes? a.
Identify any challenges, limitations, or restrictions on services and coordination. b.
What will be your agency’s strategy for addressing the challenges?
9.
Describe how your agency will meet the objectives, goals, and deliverables of the contract as detailed in the scope of work.

10.
What systems are in place to ensure that accurate records are maintained for completing all required program and fiscal reports?
11.
Describe your agency’s purpose, philosophy, goals, and objectives.
12.
How does the mission of the program align with your agency’s mission? Describe how the program will benefit/impact the community?
13.
Identify and describe any unique capabilities of your agency in delivering the service.
14.
Identify any changes, challenges, limitations, restrictions, and priorities on meeting the scope of work requirements.
15.
Identify past year program goals and summarize performance outcomes. Provide a summary of select agency accomplishments. If this is a renewal contract, describe at a minimum how has your program developed and made progress toward its goals in the past.
16.
What barriers, if any, have impacted your agency’s ability to meet program goals?
17.
Describe the agency’s outreach efforts and communication efforts for the program.
18.
If fees will be collected from recipients of any services outlined in the Contract
Requirements, state the anticipated annual amount of revenue. Also state how those revenues will be used to offset the contract’s costs.

DIVISION OF FAMILY DEVELOPMENT
REFUGEE TRAINING AND/OR VOCATIONAL SERVICES
SUPPORTIVE SERVICES AND TUITION ASSISTANCE REQUEST
Date of Referral:
Agency:
Contract #
Student’s Name:
Address:
Employed
Type of Support or
Services
Yes or No

Vocational Training
If Yes how long

Computer Training

License or Certification

*Alternative ESL (non-traditional)

*Transportation Services

Child Care
Beginning and End
Dates
Reason for
Training
Your signature below verifies that these statements are true:

Student has been in the United States a maximum of 60 months

Training is to help obtain employment or upgrade employment

No other financial assistance was received that would duplicate this request for assistance

No other resources available in the County or accessible transportation
Student Signature: Date:
Agency Staff Signature: Date:
DIVISION OF FAMILY DEVELOPMENT USE ONLY
Amount Requested: $
Amount Approved:
Amount Disapproved:
$
$
Staff Signature: Date:
Supervisor’s Approval:
Date:
* Transportation - must complete a separate transportation reporting form
* ESL – must be a certified structured program and individual must be working

Refugee Resettlement Program
Social Service Grant
Contract Compliance Standards
Compliance Standard Indicators/Documentation
Cultural and Linguistically Competent
Employment Orientation
Orientation provided in clients’ language or in partnership with a Translator.
Ensure Person eligible for services
Employment Cultural Orientation completed within
5 days of arrival in their language
Person informed of ORR program and social service grant services for up to five years
Person informed of welfare benefits & work requirements; as well as other relevant supportive services - ESL programs, and social service supports.
Person informed of ESL and Vocational Training tuition assistance through social service grant
Person informed of modes of transportation and assistance through the social service grant
Person informed of Rights and Responsibility
Person informed of Agency’s Grievance Policy
Materials and information of ORR benefits in clients language or translated
Status, arrival data, intake and case notes
Intake forms along with any documents and case notes
Signed document
Case notes
Case notes
Case notes or signed receipt
Signed document
Signed document
Employment and Self-Sufficiency Plan Plan included in case file, along with any documents and case notes.
Signed Plan Comprehensive Employment and Self Sufficient
Assessment conducted utilizing a standardized form – identifying strengths, challenges, and plan of action.
Joint self-sufficiency or Employment Plan developed with individual’s and staff signature
Referrals and Supportive Services
Signed Self Sufficiency Plan included in case file
Person referred for supportive services no later than one week after arrival
Official DFD referral document in file
Person accompanied to initial visit to Board of
Social Services with a translator if required
Case note
Medical Insurance (Medicaid) obtained within 30 to 45 days
Food Stamps obtained within 30 to 45 days
Application Date
Application Date
Transportation provided for employment related appointments
Log Sheet and case notes
Referred for ESL Assessment and Placement Test Include assessment in file, start date, and schedule.

Refugee Resettlement Program
Social Service Grant
Contract Compliance Standards
Employment Services
Readiness, Preparation, and Placement
Indicated on Employment Plan and case notes Provided Job readiness services; i.e. coaching, counseling, resume, job etiquette and expectation
Person notified of job leads, interviews or openings in accordance with Employment Plan
Document in case notes and referral services
Referred to jobs and/or interviews
Person escorted for job interview
Transportation assistance provided
Referral in case file and documented in case notes
Documented in case notes
Receipt and client signature
Placed in Job
ESL
Referred to Free ESL classes
Enrolled in certified formal ESL Instruction
Documented in case file
Referral form
Documented in case file
Training
Vocational Training Assistance Provided
Referred to Community Resource Programs
Tuition Application – must be eligible and aligned with IEP and SSP
Referral notification
DFD Referral Form
Case Management and Follow-up
Person assisted with obtaining social and supportive services at the local welfare agency
Helped obtained immigration and citizenship information and services, and documentation
Case notes and/or referral
Person assisted with school enrollment, medical services, other eligible supportive services etc.
Separate case record or section for ORR social services
Case notes
Case File
Follow-up on employment at 60, 90 & 180 days Documented in file with outcomes
Follow-up on ESL, training completion and job placement or upgrade
Staffing and Administrative Oversight
Documented in file with outcomes
Adequate staff to meet contract deliverables Full-time employment specialist staff for 50+ caseload
Staff culturally and linguistically compatible with clients servicing
Services provided in a manner that is compatible with clients language and cultural background
Knowledgeable staff on refugee and social service Experience and background
Timely submission of all required DFD reports
Collaborative partners and community resources
Submission of report
Referral types and placements
Timely complaint resolution Quick Turnaround time to resolve issue
I have read the ORR social service grant Program Deliverables and Contract Compliance Standards and agree to comply with each deliverables and standard:
Authorized Signature:
Print: Title:
Date:

Refugee Resettlement Program
Social Service Grant
Contract Compliance Standards
The below individual(s) have been admitted to the United States, and meet Office of Refugee and
Resettlement Program eligibility immigration status and identification requirements as sited in N.J.A.C
10:90-10:6.
Date:
Referring Agency:
CWA:
Staff:
APPLICANT INFORMATION
Applicant Name: ___________________________________ D.O.B.:
Family Unit Size: Language(s) Spoken:
USCIS Status: ______________ Alien #:
Date of Arrival or Status was Granted: _____________ *Match Grant Program: ( ) Yes ( ) No
Phone #: Address:

Cash Assistance
Services and/or Benefits Requesting

Food Stamps
A Translator will be present: ( ) Yes ( ) No Name of Translator:

Medicaid
Refugee Agencies
Catholic Charities Diocese of Camden
1845 Haddon Ave, Camden, NJ 08103
856-342-4100
Catholic Charities of the Archdiocese of Newark,
976 Broad St, Newark, NJ 07102
973-733-3516
Lutheran Social Ministries of NJ
189 South Broad St, Trenton, NJ 08601
609-393-4900
International Rescue Committee
10 West Grand St., Suite A,
Elizabeth, NJ 07201
908-351-5116
Jewish Family & Vocational Service of
Middlesex
32 Ford Avenue, 2 nd
floor, Milltown, NJ 08850
732-777-1940 ext 1124
Jewish Vocational Services
111 Prospect St., East Orange, NJ 07017
973-674-3672
*Individuals who are enrolled in the Match Grant Program cannot receive cash assistance benefits.
Title 45: Public Welfare - PART 400—REFUGEE RESETTLEMENT PROGRAM
Any cash grant received by the refugee under the Department of State or Department of Justice
Reception and Placement programs may not be considered in determining income eligibility.
N.J.A.C. 10:90-10.1 - Any cash assistance from the referring agency or sponsor shall be treated as unearned income.

STATE OF NEW JERSEY
DIVISION OF FAMILY DEVELOPMENT
INDEX OF REQUIRED CONTRACT DOCUMENTS
CONTRACT
ADMINISTRATOR:
NAME OF
AGENCY:
CONTRACT
NUMBER:
CONTRACT
PERIOD:
This index provides details of all required documents that must either be included with the contract package
(see checklist) or must be available on site for inspections as noted in the Document Verification Sheet
(DVS). Forms that are not included in the following pages, can be found by accessing the website at www.state.nj.us/humanservices/dfd/info and clicking on the link for Standard Contract Documents.
Document
Required with first
Contract and as
Amended
Required
Annually and as
Amended
Checklist
Required for on-site
Verificati on - DVS
Form
Check if submitted with package
Contrac t Documents
Standard Language Document (SLD) with original signatures
(additional copies requested must also have original signature)
Annex A (including summary sheet and supporting schedules)
Annex B – Budget Form with all required forms, schedules, and signatures
Executive Order 129 (Public Law 2005, Chapter 92) Source
Disclosure Certification Form
Federal Funding Accountability and Transparency Act (FFATA)
Worksheet (if applicable)
2 copies
3 copies
3 copies
●
●
Certification of Suspension and Debarment ●
1.
Copies of Subcontract/Consultant Agreement(s)
Private/Public Donor Agreement (s) for Match Responsibilities
●
●
HIPAA Business Associate Agreement (BAA)
● ●
A copy of the Acknowledgement of Receipt of the New Jersey State
Policy and Procedures for EEO/AA
2.
Liability Insurance Declaration Page and/or Malpractice Insurance
Bonding Certificate
Applicable Licenses (business and professional licenses)
●
●
●
●
Current Affirmative Action Certificate or copy of renewal application sent to Treasury (AA302 – Affirmative Action
Employee Information Report)
Health/Fire Certificates
Certificate of Occupancy or Continued Certificate of Occupancy
●
●
●

Rev. 2013
Page 2 Document
Required with first
Contract and as amended
Required
Annually and as
Amended
Checklist
Required for on-site
Verificati on – DVS
Form
●
Check if submitted with package
.
Lease or Mortgage for Property and Equipment
Certificate of Incorporation
Dated List of Names, Titles, Addresses, and Terms of Board of
S.
Directors
New Jersey Business Registration Certificate with the Division of
Revenue (Public Law 2001, Chapter 134)
Documents Required for Non Profit Agencies and as applicable for Profit Agencies
●
Copy of the most recently approved Board Minutes
Agency By-Laws
Tax Exempt Certification
●
Form 990 – Return of Organization Exempt From Income Tax
Documents Required for Profit Agencies only
U.S. Corporation Income Tax Return, Form 1120
●
●
●
●
●
●
●
Chapter 51/Executive Order 117 Vendor Certification and
Disclosure of Political Contributions (formerly known as Executive
Order 134) and copy of NJ Business Registration Certificate (see separate link)
Ownership Disclosure Form (Chapter 51) biannual
Agency Policies and Organizational Information
Organizational Chart
Personnel Manual and Employee Handbook (including job descriptions of staff) biannual
●
●
Affirmative Action Policy/Plan
Conflict of Interest Policy
Procurement Policy
Equipment Inventory (contract acquires property with DFD funds)
Audit
Notification of Licensed Public Accountant (NLPA) - include copy of Accountant’s Certification (see separate link)
Copy of Single Audit or Independent Audit for recent FY
Other Supporting Documents
Annual Report to Secretary of State
Annual Report – Charitable Organizations
●
●
●
●
●
●
●
●

Page 3 Document
Required with first contract
Required
Annually and as
Amended
Required for on-site
Verificati on – DVS
Form
Check if submitted with package
ACH – Credit authorization for automatic deposits
(for new requests only)
W-9 Form (for new Agencies only)
Additional Division/Office Specific Forms
Document Verification Sheet (DVS)
List of Agency Contracts
●
●
●
●
Standard Board Resolution (indicating authorized signatories for contracts)
●
Checklist and Copy of Award Letter ●
Purchase and Property Disclosure Form (Iran Form)
●
The contracted agency agrees to submit, to the DFD Contract Administrator, any and all changes regarding the information presented in these documents during the term of the contract. All documents should be current and reflect the approval of the agency’s Board of Directors, when applicable.
The index is for reference and is not required to be retuned with the contract package. All documents noted here are either included in the Checklist or Document Verification Sheet (DVS).
The checklist and DVS must be returned with the contract package.

DFD OFFICE OF CONTRACT ADMINISTRATION
CONTRACT CHECKLIST
CONTRACT
ADMINISTRATOR:
NAME OF
AGENCY:
CONTRACT
NUMBER:
CONTRACT
PERIOD:
PROVIDER INSTRUCTIONS :
This checklist must be completed and returned with all documents prior to contract approval. The correct number of copies and any additional Division documents must be returned to your Contract Administrator.
Forms that are not included in the following pages, can be found by accessing the website at www.state.nj.us/humanservices/dfd/info and clicking on the link to Standard Contract Documents.
Document
Number of copies to be submitted
Please check if submitted with package
If not submitted with package, indicate anticipated date of submission or reason for non-submission
Complete copy of signed DHS Standard Language
Document (SLD)
Checklist, DVS and Award Letter
Executive Order 129 Source Disclosure
Certification of Suspension or Debarment
Standardized Board Resolution indicating who is authorized to sign: Contracts and Checks
Annex A (including summary sheet and supporting schedules)
Annex B –Budget Form (Expense Summary, Details and Schedules 1-6)
List of Contracts
Equipment Inventory
Liability Insurance
Bonding Certificate
Names, Titles, Addresses and Terms of Board of
Directors
Copy of Audit Report
Current Affirmative Action Certificate or copy of renewal application sent to Treasury (AA302)
Chapter 51, Public Law 2005—
For-Profit agencies only
Federal Funding Accountability and Transparency Act
(FFATA) Worksheet (if applicable)
Copies of Subcontracts
2
1
1
1
1
1
1
1
1
3
3
1
1
1
1
1
1

Document
Notification of Licensed Public Accountant (NLPA)
(include copy of Accountant’s Certification)
Private/Public Donor Agreement for Match
Responsibilities
Organization Chart
W-9 Form (for new provider only)
Conflict of Interest Policy
As Applicable:
ACH – Credit authorization for automatic deposits
(for new requests only)
W-9 Form (for new providers)
Other: Purchase and Property Disclosure Form (Iran
Form)
Number of
Copies to be submitted
Check if data is submitted with package
If not submitted, provide date when document will be provided
1
1
1
1
1
1
1
1
1
1

NEW JERSEY DEPARTMENT OF HUMAN SERVICES
DIVISION OF FAMILY DEVELOPMENT
DOCUMENT VERIFICATION SHEET (DVS)
Contract Number Contract Period
The Provider Agency hereby certifies that the following documents are on file and are available to the
Division of Family Development (DFD) for review. The contracting Provider Agency also agrees that it will inform the DFD contract administrator of any and all changes involving these documents that may occur during the term of the contract. All documents should be current and reflect board approval.
Please do not submit documents listed below with renewal package.
Please Check as Appropriate
On File
Not
Applicable
1.
Certificate of Incorporation and NJ Business Registration
Certificate
(filed with the Division of Revenue)
2.
Annual Report to Secretary of State and Ownership
Disclosure Form
3.
Annual Report - Charitable Organization
4.
Agency By-Laws and Copy of Board Meeting Minutes
5.
Business Associate Agreement
(unless new provider or revised agreement)
6.
Business and Professional Licenses
7.
Personnel Manual and Employee Handbook
(including current job descriptions for staff)
8.
Tax Exempt Certification, Copy of Form 990
9.
U.S Corporation Income Tax Return, Form 1120
10.
Procurement Policy
11.
Certificate of Occupancy or Continued Certificate of
Occupancy and Health and Fire Certificates
12.
Property Lease/Mortgage and Equipment Leases
13.
Affirmative Action Policy and copy and acknowledgment of
NJ State Police Policy on EEO/AA
I hereby certify that all documents are current and are available for review.
Agency Director (Please Print or Type)
Agency
Agency Director’s Signature
Date

EXECUTIVE ORDER 129 CERTIFICATION
SOURCE DISCLOSURE CERTIFICATION FORM
Bidder: Solicitation Number:
I hereby certify and say:
I have personal knowledge of the facts set forth herein and am authorized to make this Certification on behalf of the Bidder.
The Bidder submits this Certification as part of a bid proposal in response to the referenced solicitation issued by the Division of Purchase and Property, Department of the Treasury, State of New Jersey (the
“Division”), in accordance with the requirements of Executive Order 129, issued by Governor James E.
McGreevy on September 9, 2004 (hereinafter “E.O. No. 129”).
The following is a list of every location where services will be performed by the bidder and all subcontractors.
Bidder or Subcontractor Description of Services Performance Location(s) by
Country
Any changes to the information set forth in this Certification during the term of any contract awarded under the referenced solicitation or extension thereof will be immediately reported by the Vendor to the
Director, Division of Purchase and Property (the “Director”).
I understand that, after award of a contract to the Bidder, it is determined that the Bidder has shifted services declared above to be provided within the United States to sources outside the United States, prior to a written determination by the Director that extraordinary circumstances require the shift of services or that the failure to shift the services would result in economic hardship to the State of New
Jersey, the Bidder shall be deemed in breach of contract, which contract will be subject to termination for cause pursuant to Section 3.5b.1 of the Standard Terms and Conditions.
I further understand that this Certification is submitted on behalf of the Bidder in order to induce the
Division to accept a bid proposal, with knowledge that the Division is relying upon the truth of the statements contained herein.
I certify that, to the best of my knowledge and belief, the foregoing statements by me are true. I am aware that if any of the statements are willfully false, I am subject to punishment.
Bidder:
Name of Organization or Entity
By:
Print Name:
Title:
Date:

New Jersey Department of Human Services
Division of Family Development
Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion
Lower Tier Covered Transactions
1.
The prospective lower tier participant certifies, by submission of this proposal, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by an Federal or State department or agency.
2.
Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal.
Name and Title of Authorized Representative __________________________________
Signature _________________________
Date _____________________________
This certification is required by the regulations implementing Executive order 12549, Debarment and
Suspension, 29 CFR Part 98, Section 98.510

STATE OF NEW JERSEY
DIVISION OF FAMILY DEVELOPMENT
STANDARDIZED BOARD RESOLUTION FORM – page 1 of 2
Supporting Information for Contract #:
Contract Period:
Agency: to
Certification:
We certify that the information contained in, or attached to, this contract document is accurate and complete.
__________________________________ ________________________
Chair, Board of Directors
(Original signature)
Date
__________________________________ ________________________
Executive Director
(Original signature)
Date
Please List Authorized Signatories for contract documents, checks, and invoices:
(List full name and title)
Name Title
Name
Name
Title
Title

STANDARDIZED BOARD RESOLUTION FORM – page 2 of 2
The Board endorses the following commitments as defined in this document:
1.
Health Insurance Portability and Accountability Act (HIPAA)*
Specific to HIPAA (Health Insurance Portability and Accountability Act), the above noted
Provider Agency is deemed a covered entity and must submit the required Business Associate
Agreement.
Once executed, the BAA will be included in the Department’s official contract file. The BAA will be considered applicable for this contract. Any changes in the Provider Agency’s status, information or the content of the BAA, is the responsibility of the contracted Provider Agency to revise the BAA.
The Board agrees to notify the Department of any change in its BAA Status and provide the appropriate information within 10 business days.
2.
Legal Advice
The Board acknowledges that the Division of Family Development does not and will not provide legal advice regarding the contract or any facet of its relationship with the Provider Agency. The
Board further acknowledges that any and all legal advice must be sought from the Provider
Agency's own attorneys and not from the Division of Family Development.
3.
Public Law 2005, Chapter 51
The Board agrees that the Public Law 2005, Chapter 51 (formerly known as Executive Order
134) compliance forms submitted with the contract is accurate.
4.
Public Law 2005, Chapter 92
The Board agrees that the Public Law 2005, Chapter 92 (formerly known as Executive Order
#129) compliance forms submitted with the contract are accurate.

STATE OF NEW JERSEY
DIVISION OF FAMILY DEVELOPMENT
List of Contracts/Grants
Check here if this information already appears on the Annex B, Contract Information Form. If so, do not duplicate information here.
Contracting
Division/Office
Program
Name
Type of
Service
Contract
Number
Contract
Term Amount
Division/Office
Contact
Person and
Phone
Number
Provider Agency
Contact Person and Phone
Number

CONTRACT FORMS
Available at the DFD website:
AA 302
Federal Financial Accountability Transparency Act (FFATA) Worksheet
Notification of Licensed Public Accountant
Purchase and Property Disclosure Form (Iran Form)

ANNEX B - Helpful Hints

FY 14 and FY 15 Federal Award Information
TANF (SH, TS, NC, LG, DV, SF, UF)
FY 14 - Grant Number G-1402NJTANF CFDA 93.558
FY 15 - Grant Number G-1502NJTANF
CCDF (UC, KU, SP, TP, FS)
CFDA 93.558
FY 14:
Grant Number 2014G996005
Grant Number 2014G999004
Grant Number 2014G999005
FY 15:
Grant Number 2015G996005
Grant Number 2015G999004
Grant Number 2015G999005
Refugee:
Resettlement
CFDA 93.575 Discretionary Contract
CFDA 93.596 Mandatory
CFDA 93.596 Matching
CFDA 93.575 Discretionary Contract
CFDA 93.596 Mandatory
CFDA 93.596 Matching
FY 14:
Grant No. 1401NJRSOC
Refugee – School Impact (RF)
FY 13:
Grant number is 90ZEO165-01-02
FY 14:
Grant number is 90ZE0165-02-01
Refugee – Cuban Haitian (RF)
FY 13:
Grant number is 90RQ0039-01
FY 14:
Grant number is 90RQ0039-02-01
CFDA 93.566
CFDA 93.576
CFDA 93.576
CFDA 93.576
CFDA 93.576

Refugee REAP (RF)
FY 14:
Grant number is 90RT0185-01-02
Food Bank (FB) Department of Agriculture
FY 14
Grant Number is 1NJ400404
SANDY
FY 14
Grant Number is 2013G99WREE
DCM
FY 13:
Grant Number FEMA-DR-4086
CFDA 93.576
CFDA 10.561
CFDA 93.667
CFDA 97.088