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Contract# ___________________ <br />ANOKA COUNTY HUMAN SERVICES <br />CONTRACTOR INFORMATION SHEET <br />Please review the following information for accuracy and Angie Rodine <br />completeness, indicate any changes, sign and return to: Anoka County Human Services <br />rd <br />2100 3 Ave, Suite 500 <br />Anoka, MN 55303 <br /> <br />LEGAL NAME FOR CONTRACTOR:____________________________________________________________ <br />(Legal name and name on Certificate of Insurance must be exactly the same in order for County Signatures to be obtained on the <br />Contract.) <br /> <br />Doing Business As: ____________________________________________________________ <br /> <br />Business/Corporate Address: ____________________________________________________________ <br /> <br /> ____________________________________________________________ <br /> <br /> ____________________________________________________________ <br /> <br /> <br />National Provider Identification (NPI) #: ______________________________________________________ <br /> <br />Federal Tax Identification #: ______________________________________________________ <br />NOTICE: Federal Business Tax ID/Social Security Number is needed for tax purposes as mandated by Section 1211 of the Tax Reform Act <br />of 1976 and Minn. Stat 270.66. This information will be shared with the Minnesota Department of Revenue, the Minnesota Department <br />of Human Services, the Internal Revenue Service, and the U.S. Department of Health, Education and Welfare for the purposes of <br />administering the income tax, child support obligation and social security tax programs. <br /> <br />Individual who Contractor is designating to receive notice under the contract and to act as the responsible <br />authority for data requests under the Minnesota government data practices act (Minn. Stat. Chap. 13): <br /> <br />Name: Phone: Fax: Email: <br />_________________________________________________________________________________ <br /> <br />Signature (Required): _______________________________________ Date: ________________________ <br /> <br />Insurance Agency:_____________________________Name of Agent: ___________________________ <br />Telephone Number of Insurance Agent: _______________________________________ <br />Person Completing this Form: <br /> <br />Name:___________________________________ Title:____________________________________ <br /> <br />Phone: ____________________ Fax:___________________ Email: _____________________________ <br /> <br /> <br />