Contractor Stipend Request

Primary Contact Information

Please complete the contact information. The primary contact should be the contact to direct any questions to. Enter the company name and mailing address for payment.

Please note: A retention agreement with a Community Action Agency must be on file to be eligible for Stipends. Additionally, a W9 must be filed with MPHI.

Question Title

* 1. Primary Contact

Name

Email Address

Phone Number

Question Title

* 2. Provide the full company name and mailing address:

Company *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Question Title

* 3. Contractor W9

A W9 must be on file with MPHI for payment. Attach here if it has not already been submitted. Alternatively, please email to mdhhs-bcaeo@michigan.gov with "W9 for (Company Name) - Stipend Payment' in the subject line.

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