ESBD_488564_1770669803524_Form 5 - Conflict of Interest Certification (VR 3444).pdf

VR3444 (03/20) Conflict of Interest Certification Page 1 of 2

Texas Workforce Commission Vocational Rehabilitation Services

Conflict of Interest Certification Instructions:

• For response to an Electronic State Business Daily (EBSD) posting follow the instructions in the

ESBD posting. All sections must be completed at application.

• For updates to information on file with TWC record the required information and gain signatures.

Submit updated forms to the assigned Contract Manager and QASVRS or RPSS.

• 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 the completed application, attachments, and supporting documentation for your records.

Reason for Submission

Date of submission:

Application package Solicitation ID:

Update of information due to change in information on file. For example, qualifications change.

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:

Conflict of Interest Certification Acknowledgment and Signature

Contractors and potential contractors must not offer, give, or agree to give TWC staff anything of value. Anything of value includes prepared foods, gift baskets, promotional items, awards, gift cards, meals, or promises of future employment. If a violation occurs, corrective action is required and may include contract termination or disqualification from receiving a future contract with TWC. Real or apparent conflicts of interest might occur when a former VR employee becomes an employee or a subcontractor of a TWC contractor. A contractor must not:

• hire, contract with, or accept as a volunteer any current employees of TWC, VR, or ILS-OIB;

• hire, contract with, or accept as a volunteer any former employees of TWC, VR, or ILS-OIB earlier than 12 months after the separation date, if the former employee will provide contracted services as defined in the VR SFP manual and/or Texas Government Code §572.069; or

• knowingly request or obtain confidential information from a state employee for the benefit of the contractor, personally or professionally.

VR3444 (03/20) Conflict of Interest Certification Page 2 of 2

A customer is acting in a dual role when the Texas Workforce Solutions–VR (TWS-VR) customer’s IPE supports the customer:

• obtaining employment from an existing contractor to provide services to other TWS-VR customers; or

• becoming a TWC-VR contractor to provide services to TWS-VR customers.

When the TWS-VR customer is in a dual role, for a period of 12 months following the closure of his or her case, the customer:

• is prohibited from providing services to any customer who is assigned to the customer’s same TWS-VR counselor; and/or

• may not receive service authorizations from the office to which the customer’s VR counselor is assigned.

An exception may be granted when a VR3472, Contracted Service Modification Request, is approved for any of the following reasons:

• The customer lives in a rural or other area where no other providers are available to serve the customer(s);

• The contractor has a skill or capability that no other available and accessible provider has. For example, in situations where a customer is not proficient in English, the contractor speaks the customer's language as well as English.

The scenarios above do not make up a complete list of real or apparent conflicts of interest. Failure to disclose a conflict of interest can result in contract termination, disqualification from receiving a future contract, and/or recoupment of payments.

Signatures I, the legally authorized representative, have been named by the entity and have the authority to certify

• the entity acknowledges the conflict of interest statements above,

• the entity recognizes they must comply to any and all conflict of interest content found in the

TWC VR Standards for Provider Manual, and/or contract, if awarded,

• the information provided in this form is complete and accurate.

Typed name:

Handwritten Signature:

X

Date: