ESBD_File_283022_FY23_HHS0011802_Package 2_Application_02042022.docx

OUT-OF-STATE COURTESY SUPERVISION SERVICES

REQUEST FOR QUALIFICATIONS

APPLICATION

INSTRUCTIONS

1. Application must be completed and signed in Section 6 (Certification) for it to be accepted by DFPS.

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.

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

SECTION 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

Person Authorized to Sign Contract:

Contact for Service Delivery:

Contact for Invoicing:

SECTION 2 -ELIGIBILITY REQUIRMENTS

(See Section 2.16 of the Open Enrollment for the Minimum Qualifications for Contractors)

2.1 Does the Applicant hold a Social Work License ?

2.2 Does the Applicant have two years of professional service in the child welfare system?

SECTION 3 - CONTRACTOR BACKGROUND

3.1 Does the Applicant have contracts with DFPS or other Texas State Agencies?

|_| Yes |_| No

If yes, Is the Applicant's organization currently under any corrective action plan for any of the contracts with DFPS or Texas State Agencies?

|_| Yes |_| No

3.2 Have any contracts with DFPS or other Texas State Agencies been terminated for cause in the last five (5) years?

|_| No |_| Yes (Provide copies of termination notice)

SECTION 4 - INSURANCE

Review the Insurance requirements in Open Enrollment Section 2.17. Applicants must meet all requirements as outlined. Indicate in the table below, if requirement is met

Professional Liability Insurance

|_|Yes |_|No

Commercial Crime Insurance

|_|Yes |_|No

Attach a copy of the Certificate of Insurance (COI) or equivalent document (e.g., ACORD Certificate of Insurance or a copy of the policy) for each insurance requirement currently in force and referenced in the table above.

NOTE ON SOLE PROPRIETORS - Sole Proprietors with no employees or other individuals with access to fiscal resources such as unpaid volunteers or independent contractors, are exempt from this insurance requirement.

SECTION 5 - SERVICE DELIVERY LOCATION

Services will be provided at the following Residential Treatment Center/Facility:

Facility Name:

Location (including the State):

SECTION 6 - 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 Request for Qualifications.

Signature of Authorized Representative

Date

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

Texas Department of Family & Protective Services Out-of-State Courtesy Supervision Services Open Enrollment #HHS0011802

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 and Service Delivery Area

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