10-Child Support Affidavit TJJD.pdf
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- Solicitation number
- 26/0028
- Issued by
- Harris County, Texas
About this file
This is an Affidavit of Eligibility to Receive State Funds form (TJJD-FIS-180) issued by the Texas Juvenile Justice Department, applicable to vendors and contractors seeking payment from state funds in connection with contracts, grants, or loans. The affidavit establishes eligibility requirements and certification procedures for individuals and business entities contracting with the State of Texas. The form requires contractors to certify their compliance with child support obligations under Texas Family Code Section 231.006, specifically addressing whether any principals of the contracting entity are delinquent in child support payments by more than 30 days. Contractors must provide complete identifying information for all relevant parties, including names, Social Security numbers, and ownership percentages for sole proprietors, partners, shareholders, or owners with at least 25 percent ownership interest.
The affidavit establishes that contractors ineligible to receive state funds are those with child support obligors delinquent by more than 30 days, unless all arrearages are paid, a written repayment agreement or court order is in place, or a court-ordered exemption has been granted. The contractor assumes responsibility for verifying the child support status of all principals and certifies that inaccurate certification may result in contract termination and payment withholding. The form requires notarization and is applicable to non-governmental entities and non-nonprofit corporations, with exemptions for governmental entities and nonprofit organizations. This affidavit is a prerequisite certification document for the Educational Advocacy, Technical Support and Legal Assistance Program RFP for the Harris County Juvenile Probation Department.
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Text version
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: _____________________________
| Printed Name: |
| Social Security Number: |
| Percent Ownership: |
| Printed Name_2: |
| Social Security Number_2: |
| Percent Ownership_2: |
| Printed Name_3: |
| Social Security Number_3: |
| SIGNED this: |
| day of: |
| 20: |
| Printed Name_4: |
| Percent Ownership_3: |
| Check Box1: Off |
| Check Box2: Off |
| Check Box3: Off |
| Check Box4: Off |
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