11-Form 10 - Entity’s Physical Location(s) – Part A (VR 3442A).pdf
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- Solicitation number
- 3202600127
- Issued by
- Texas
About this file
This is a Form 10 Entity's Physical Location(s) documentation submitted to the Texas Workforce Commission (TWC) Vocational Rehabilitation (VR) division in support of an application to provide Senior Keys to Independence Program (SKIP) services. The form is part of the open enrollment application process for qualified service providers seeking to deliver SKIP services to Older Individuals who are Blind (OIB) customers across TWC-VR Workforce Solutions offices statewide. Applicants must complete this form to document and verify their physical operational locations as part of meeting all eligibility requirements and specifications for service provision under this open enrollment opportunity.
The Form 10 serves as a critical component of the application verification process, requiring applicants to clearly identify and substantiate all physical locations from which they will deliver SKIP services. This documentation ensures that service providers maintain adequate infrastructure and accessibility for serving OIB customers across their service delivery areas. Completion and accurate submission of this form is mandatory for applicants to demonstrate compliance with TWC's location and operational requirements for the SKIP program.
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Text version
VR3442A (12/22) Entity’s Physical Location Part A – Service Contracts Certification Statement Page 1 of 1
Texas Workforce Commission Vocational Rehabilitation Services
Entity’s Physical Location(s) Part A – Service Contracts Certification Statement
Instructions:
• For response to an Electronic State Business Daily (EBSD) posting, follow the instructions in the
ESBD posting, otherwise submit updated forms to the Quality Assurance Specialist for VR (Q) or Regional Program Support Specialist (RPSS).
• Follow instructions on the form and in the TWC VR Standards for Providers.
• Type all information on form using a computer and get all required signatures.
• Complete all sections of the form. Record “N/A” (not applicable) if a question does not apply.
• Keep a copy of your submitted form with attachments and supporting documentation for your records.
Reason for Submission
Date of submission: Solicitation ID: or Contract #:
Application package
Update of information due to change in information on file. For example, new physical location.
Other: Specify:
Entity’s Information Entity: The business that is requesting or has been granted the bilateral contract with TWC to provide services on behalf of VR customers.
Entity’s legal name:
Entity’s “doing business as” (DBA) name:
Provide at least one of the following:
Employer Identification Number (EIN) (9 digits, issued by IRS):
Last four digits of the sole proprietor’s Social Security Number:
Certification of Entity’s Physical Location Status Physical location: Is a location the contractor owns, leases, or uses as dedicated space to provide goods and/or services to customers and/or attend meetings with customers.
NOTE: Physical locations do not include community sites such as state, federal, city, county, or other public meeting spaces. Contactors that provide all services at community sites that are not owned or leased by the contractor are not required to maintain a physical location.
The entity has one or more physical locations as defined above. Yes No
If yes, a VR3442B MUST be completed for each location.
I, the legally authorized representative, have the authority to certify:
• all inforamtion on this form is true and accurate; and
• the entity acknowledges it must update this form anytime information changes.
Typed name:
Handwritten Signature:
X
Date:
File details come from the government source that posted it. Updated .