ESBD_548201_1786394892804_Form 10-Entitys Physical Location(s) Part A (VR 3442A).pdf
PDF 119 KB Posted
- Attached to
- Open Enrollment (OE) for Employment Services
- Solicitation number
- 3202600194
- Issued by
- Texas
About this file
This is an Entity's Physical Location Certification Statement form issued by the Texas Workforce Commission (TWC) Vocational Rehabilitation Services division. The form serves as a certification document for entities requesting or maintaining bilateral contracts with TWC to provide services to vocational rehabilitation customers. The form requires entities to declare their physical location status and provide comprehensive business information including legal entity 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. Entities must certify whether they maintain one or more physical locations defined as spaces owned, leased, or dedicated by the contractor to provide goods, services, or attend customer meetings, explicitly excluding community sites such as state, federal, city, or county public meeting spaces. If physical locations are maintained, a separate VR3442B form must be completed for each location.
The form requires completion of all sections with typed information and authorized signatures from a legally authorized representative who certifies the accuracy of all submitted information and acknowledges the obligation to update the form whenever changes occur. The submission may be made in response to an Electronic State Business Daily (EBSD) posting or submitted as an update to the Quality Assurance Specialist for VR or Regional Program Support Specialist (RPSS). The form permits entities providing all services at non-owned or non-leased community sites to operate without maintaining a dedicated physical location, streamlining requirements for certain service delivery models. Entities must retain copies of submitted forms with all attachments and supporting documentation for their records.
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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 .