5-Attachment 05-VR5053 Application Statement.pdf
PDF 579 KB Posted
- Solicitation number
- 3202600157
- Issued by
- Texas
About this file
This is an Application Statement form for the Older Individuals Who are Blind (OIB) Services program administered by the Texas Workforce Commission Vocational Rehabilitation Services (TWC-VRS). The document serves as the official application for individuals seeking Independent Living Services through the OIB program. Applicants applying for services must certify their intent to continue living as independently as possible and confirm receipt of program rights and responsibilities documentation titled "Can We Talk?" The form requires applicants to acknowledge understanding of the Client Assistance Program (CAP) availability and appeal procedures, as well as customer participation requirements in service costs. Applicants must also authorize TWC-VRS to collect medical, personal, and family financial information necessary for eligibility determination and service plan development.
The application requires signatures from the applicant, guardian or representative if applicable, the TWC-VRS representative, and a witness if any party signs with a mark. All applicants must provide accurate financial resource information and confirm they have received and signed releases authorizing information collection, which may be revoked at any time except for actions already taken and automatically expire upon cessation of service eligibility or receipt. This form represents the foundational documentation required for individuals seeking access to vocational rehabilitation services for older individuals who are blind across all TWC-VR Workforce Solutions offices throughout Texas.
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Text version
VR5053 (12/23) Application Statement for OIB Program Page 1 of 1
Texas Workforce Commission Vocational Rehabilitation Services
Application Statement for OIB Program
Older Individuals Who are Blind (OIB) Services With few exceptions, you are entitled, on request, to be informed about the information that the Texas Workforce Solutions Vocational Rehabilitation Services (TWS/VRS) collects about you. You are also entitled to receive and review the information, and to have TWS/VRS correct information about you that is incorrect (Sections 552.021, 552.023, and 559.004 of the Government Code). .
Applicant Information
Last name: First name:
Middle name: Social Security number:
I am applying for services. My signature below certifies to the following.
Service Outcome I am applying for Independent Living Services for the purpose of continuing to live as independently as possible.
Rights
• I have received a copy of “Can We Talk?”, which contains information about my rights and responsibilities, and procedures for appeals. I have read and understand its contents.
• The Client Assistance Program’s availability and purpose have been explained to me. I understand that CAP’s contact information is in my copy of “Can We Talk?”.
Financial Resources
The rules on customer participation in the cost of services have been explained to me. In providing information to the TWS/VRS about my family’s financial resources, I have provided information that is true and correct.
Permission to Collect and Receive Confidential Information
I understand that the TWS/VRS is authorized to collect certain medical and/or personal and family information to determine eligibility and to develop a service plan. I have received and signed a release for this purpose and understand that it (1) may be revoked at any time except for action already taken based on the consent, and
(2) expires automatically when the person for whom records are being collected is no longer applying for or receiving services from TWS/VRS.
Signatures
Applicant name:
Applicant signature:
X
Date:
Printed guardian and/or representative name (if applicable):
Guardian and/or representative signature:
Printed TWS/VRS representative name:
TWS/VRS representative signature:
Printed witness name (if one of the above signs with a mark):
Witness signature:
f orm
EXAMPLE
File details come from the government source that posted it. Updated .