10-Child Support Affidavit TJJD.pdf

Affidavit of Eligibility to Receive State Funds

TEXAS

JUVENILE

JUSTICE

DEPARTMENT

TJJD-FIS-180 (6/13) www.tjjd.texas.gov Page 1 of 2

TEXAS JUVENILE JUSTICE DEPARTMENT

CHILD SUPPORT AFFIDAVIT

TEXAS FAMILY CODE, SECTION 231.006

INELIGIBILITY TO RECEIVE STATE GRANTS, LOANS OR

RECEIVE PAYMENT ON STATE CONTRACTS

A child support obligor who is more than 30 days delinquent in paying child support and a business entity in which the obligor is a sole proprietor, partner, shareholder, or owner with an interest of at least 25 percent is not eligible to receive payments from state funds under a contract to provide property, materials or services, or receive a state-funded grant or loan until:

1. All arrearages have been paid;

2. The obligor is in compliance with a written repayment agreement or court order as to any existing delinquency; or

3. A court-ordered exemption has been granted.

CERTIFICATION STATEMENT

Under Section 231.006, Family Code, the vendor or applicant certifies that the individual or business entity named in this contract, bid, or application is not ineligible to receive the specified grant, loan, or payment and acknowledges that this contract may be terminated and payment may be withheld if this certification is inaccurate. The contractor understands that it is the contractor’s responsibility to verify whether a child support obligor who is more than 30 days delinquent is the sole proprietor, partner, shareholder or owner with an ownership interest of at least 25%.

1. The contractor certifies that:

The individual or partner, shareholder, or owner of the business entity IS NOT a parent that has been ordered by a Texas Court to pay child support under Title 5 of the Texas Family Code. OR

The individual or partner, shareholder, or owner of the business entity IS a parent that has been ordered by a Texas Court to pay child support under Title 5 of the Texas Family Code.

2. The contractor identified below IS NOT a governmental entity or a nonprofit corporation and certifies to the following:

The contractor is: (check one):

An individual or sole proprietor, or

A business entity (corporation, partnership, joint venture, limited liability company, association, etc.)

TJJD-FIS-180 (6/13) www.tjjd.texas.gov Page 2 of 2

3. The contractor certifies that the following is a complete list of the names and social security numbers of either (a) the individual or sole proprietor who is the contractor or (b) each partner, shareholder, or owner with an ownership interest of at least 25% of the contractor/business entity:

Printed Name: _____________________________________________________________________

Social Security Number:__________________________________ Percent Ownership: __________

Printed Name: _____________________________________________________________________

Social Security Number:__________________________________ Percent Ownership: __________

Printed Name: _____________________________________________________________________

Social Security Number:__________________________________ Percent Ownership: __________

SIGNED this ______ day of ______________, 20_____.

Signature of Contractor

Signature Authorized Representative

Printed Name

SWORN TO AND SUBSCRIBED before me on the ______ day of ___________, 20____.

Notary Public, State of _____________ Notary’s Printed Name

My Commission Expires: _____________________________