8-Form 10-Entity’s Physical Location(s) Part A (VR 3442A).pdf
PDF 119 KB Posted
- Solicitation number
- 3202600155
- Issued by
- Texas
About this file
This is a certification form for entity physical location requirements issued by the Texas Workforce Commission (TWC) Vocational Rehabilitation Services division in connection with service contracts. The form, VR3442A, is utilized when entities request or have been granted bilateral contracts with TWC to provide services to Vocational Rehabilitation (VR) customers. The document requires contractors to certify whether they maintain one or more dedicated physical locations that they own, lease, or use to provide goods and services to customers and attend customer meetings. Community sites such as public meeting spaces do not qualify as physical locations under this definition, and contractors providing all services exclusively at such community sites are not required to maintain a dedicated physical location. If an entity maintains physical locations, a supplementary form VR3442B must be completed for each location.
The certification must be completed with all required information typed on the form and signed by the legally authorized representative of the entity. The entity must provide its legal name, doing business as name if applicable, and either its Employer Identification Number or the last four digits of the sole proprietor's Social Security Number. The legally authorized representative certifies that all information on the form is true and accurate and acknowledges the obligation to update the form whenever information changes. This form applies to the open enrollment opportunity for Orientation and Mobility Services to be provided to TWC-VR customers across all Workforce Solutions offices throughout Texas.
View the file
Other files
Show all 20
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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 .