ESBD_520882_1779974211755_Form 10-Entitys Physical Location(s) Part A (VR 3442A).pdf
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- Solicitation number
- 3202600155
- Issued by
- Texas
About this file
This is a certification form for entity physical locations submitted to the Texas Workforce Commission (TWC) Vocational Rehabilitation Services in response to a service contract solicitation. The form serves as a certification statement regarding whether an entity maintains dedicated physical locations to provide goods and services to customers or attend customer meetings. Entities submitting this form must complete all sections and provide either an Employer Identification Number or the last four digits of a sole proprietor's Social Security Number. If the entity maintains one or more physical locations as defined—locations that the contractor owns, leases, or uses as dedicated space—then a completed VR3442B form must be submitted for each location. The form explicitly excludes community sites such as state, federal, city, county, or other public meeting spaces from the definition of required physical locations, and contractors providing all services at non-owned or non-leased community sites are not required to maintain a physical location.
The legally authorized representative must certify that all information provided is true and accurate and acknowledge the obligation to update the form whenever information changes. The submission may be made in response to an Electronic State Business Daily posting, as an update to existing information on file due to changes such as new physical locations, or for other specified reasons. Contractors must maintain copies of their submitted forms along with all attachments and supporting documentation for their records and follow all instructions outlined in the TWC VR Standards for Providers.
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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 .