ESBD_548225_1786466927498_Form 10-Entitys Physical Location(s) Part A (VR 3442A).pdf
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- Attached to
- Open Enrollment (OE) For Project SEARCH
- Solicitation number
- 3202600209
- 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 division in response to service contract solicitations. The form serves as Part A of a two-part certification process and requires entities requesting or holding bilateral contracts with TWC to verify their physical location status and provide updated information when changes occur. Entities must complete this form along with supplementary VR3442B forms for each physical location they maintain. The form defines physical locations as spaces that contractors own, lease, or use as dedicated areas to provide goods and services to customers or conduct customer meetings, explicitly excluding community sites such as public meeting spaces that are not owned or leased by the contractor. Contractors providing all services at community sites are exempt from maintaining a physical location.
The form requires completion of all sections with specific information including the entity's legal name, doing business as name, employer identification number or last four digits of the sole proprietor's social security number, reason for submission, and the date of submission. The legally authorized representative must certify under penalty of law that all information provided is true and accurate and must sign and date the form, acknowledging the obligation to update the form whenever information changes. Submission instructions vary based on whether the response is to an Electronic State Business Daily posting or represents an update to existing information on file.
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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 .