ESBD_547773_1786134575634_Form 10-Entitys Physical Location(s) Part A (VR 3442A).pdf
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- Attached to
- 3202600208 Open Enrollment (OE) for Assistive Technology (AT) Services for Customers with Visual Impairments
- Solicitation number
- 3202600208
- Issued by
- Texas
About this file
This document is a VR3442A certification form issued by the Texas Workforce Commission (TWC) Vocational Rehabilitation Services division for use in service contract submissions. The form requires entities seeking or currently holding bilateral contracts with TWC to certify their physical location status and provide updated information when circumstances change. Entities must complete all sections of the form, including their legal name, doing business as (DBA) name, and either an Employer Identification Number (EIN) or the last four digits of a sole proprietor's Social Security Number. The form distinguishes between dedicated physical locations that contractors own, lease, or use as dedicated space to serve customers and conduct meetings versus community sites such as public facilities, noting that contractors providing all services exclusively at community sites are not required to maintain their own physical location.
The form requires a legally authorized representative to certify under penalty that all information provided is true and accurate and to acknowledge that the entity must update the form whenever information changes. If an entity indicates it maintains one or more physical locations, it must submit a completed VR3442B form for each location. This certification statement serves as Part A of the submission requirements and must be submitted either in response to specific Electronic State Business Daily (ESBD) posting instructions or to the appropriate Quality Assurance Specialist for VR or Regional Program Support Specialist (RPSS) as part of the application package for service contracts related to the Open Enrollment for Assistive Technology Services for Customers with Visual Impairments opportunity.
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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 .