ESBD_488564_1770669923622_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 certification form (VR3442A) from the Texas Workforce Commission (TWC) Vocational Rehabilitation Services program used to document an entity's physical location status for service contract applicants. The form requires submission in response to Electronic State Business Daily (ESBD) postings or updates to the Quality Assurance Specialist or Regional Program Support Specialist. Entities must provide their legal name, doing business as (DBA) name, and either an Employer Identification Number or the last four digits of a sole proprietor's Social Security Number. The form requires certification that any physical location maintained by the contractor constitutes dedicated space owned, leased, or used to provide goods and services to customers or conduct customer meetings, excluding community sites such as public meeting spaces operated by state, federal, city, or county entities.
The form requires the legally authorized representative to certify under signature that all information provided is true and accurate and to acknowledge the obligation to update the form when any information changes. Contractors providing all services exclusively at community sites not owned or leased by the contractor are not required to maintain a physical location. If the entity maintains one or more physical locations as defined, a supplemental form (VR3442B) must be completed for each location. The form includes sections for recording the submission reason, solicitation or contract identification numbers, and the date of submission, with instructions to maintain copies of the submitted form along with all attachments and supporting documentation for records.
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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 .