ESBD_File_206490_HHS0007902_FY21_OOS_Adoption_Services_Application and Required Forms_FINAL.docx

5.1 OUT OF STATE ADOPTION SERVICES OPEN ENROLLMENT

APPLICATION

INSTRUCTIONS

5.1.1 Application must be completed and signed in Section 4 (Certification) for it to be accepted by DFPS.

5.1.2 Applicant will submit Application and all required documents in the format and order described in Appendix A to the Point of Contact in Open Enrollment Section 1.2.

5.1.3 If DFPS has difficulty accessing the Applicant’s documents, the Applicant will be required to re-submit documents as directed by DFPS.

Texas Department of Family & Protective Services Out of State Adoption Services Enrollment Number HHS0007902

Instructions

1. APPLICANT INFORMATION

Vendor ID Number:

Federal ID Number – If different from Vendor ID:

Applicant:

Parent Organization:

Doing Business As Name (DBA) or Parent Organization – If different from Legal Name above:

Attach a copy of Assumed Name Certificate

If an Applicant has a Parent Organization, attach a copy of the agreement between the Applicant and the Parent Organization

Type of Applicant – Check appropriate box(es) and attach documentation as indicated

|_| Sole Proprietorship

Charter Number:

Attach a copy of Certificate of Incorporation

Are you currently registered with the Texas Secretary of State?

|_| Yes |_| No

Person Authorized to Sign Contract:

Contact for Service Delivery:

Contact for Invoicing:

2. ELIGIBILITY REQUIRMENTS

(See Section 2.15 Contractor Minimum Qualifications of the Open Enrollment)

2.1 Does Applicant hold a valid and current Child-Placing Agency License (State Adoption License) at the time this Application is submitted?

2.2 Does Applicant or the applicant’s staff members completed at least six (6) Special Needs Adoptions (Section 2.15.1) at the time of this Application is submitted?

2.3 Does Applicant meet the insurance requirements in Section 2.16 of the Open Enrollment?

3. SERVICE DELIVERY AREA

(See Section 2.4 of the Open Enrollment)

The children served by Out of State Adoption Services are located throughout the eleven (11) DFPS geographic regions in the State of Texas.

4. CERTIFICATION

I certify that the information provided in this application is, to the best of my knowledge, complete and accurate; that the named legal entity has authorized me, as its representative, to submit this application; and that the legal entity complies with all terms of this Open Enrollment.

Signature of Authorized Representative

Date

Name of Authorized Representative (Printed) Title of Authorized Representative (Printed)

Texas Department of Family & Protective Services Out of State Adoption Services Enrollment Number HHS0007902

Application

Appendix A – Application Instructions

1. Applicant must submit a completed Application and Required Forms, as applicable, in the order listed below for File Folder 1 and File Folder 2.

2. Access the forms by the link or icon provided below by holding down the "Ctrl" key while clicking on the link.

3. Save forms in an electronic file.

4. For the Application and the forms that require signature, print, sign and scan in an electronic format. Scanned documents must be clear and legible.

5. Attach File Folders 1 and 2 to email and submit the completed Application to the Point of Contact listed in the Open Enrollment Section 1.2.

Appendix B – Required Forms

File Folder 1: Application

Required or If Applicable

File Folder 2: Required Forms

The following forms are located on the DFPS public website, Doing Business with DFPS, Contracting Forms: https://www.dfps.state.tx.us/Doing_Business/forms.asp

Background Clearances

The following form is located on the DFPS public website, Doing Business with DFPS, Contracting Forms, Regional CPS Contracting Forms, General Documents:

https://www.dfps.state.tx.us/Doing_Business/Purchased_Client_Services/Regional_CPS_Contracts/forms.asp