Supervised Visitation Services PEN # HHS0000011 Attachment B Required Forms (062513) Page 1

Attachment B Required Forms

Notes

1.Forms must be completed and signed.Note: Review each form in its entirety to ensure that applicable sections are completed.

2. Forms requiring an original signature must be signed and saved in the electronic(pdf) copy.

3. Some forms may include special instructions or clarification provided under thename of the form in the column titled "Name."

4. If a form does not apply to you or your organization, mark the form "N/A", includeyour operation's name, sign, date, and return the form with response package.

Texas Dept. of Family and Protective Services

Signature Authority Designation Form 2031 September 2014

All Contractors/Potential Contractors are required to fill out and submit this form.

Completion of this form designates signature authority for Contractor:

The Contractor may: (1) designate additional signature authority by including the additional signature authority’s name and title; or (2) verify that the signature below is the only signature authority designated for contracting with DFPS.

The Contractor understands that there is an ongoing duty to notify DFPS in writing of any change to signature authority during the term of the contract with DFPS. The Contractor verifies that the signature(s) below is a complete, true and correct representation of signature authority.

Printed Name Signature of Authorized Representative

Title of Authorized Representative Date

Legal Name of Contractor/Potential Contractor Contract or Procurement Number

The Designated Signature Authority as referenced above has authorized the following person(s) listed below to also approve and sign on the contract functions as indicated. Please note that both the printed name and signature is required for each authorized individual.

Printed Name Title Function Signature

Printed Name Title Function Signature

Printed Name Title Function Signature

Printed Name Title Function Signature

Printed Name Title Function Signature

Printed Name Title Function Signature

I certify that the person(s) indicated above are designated as “Authorized Official(s)” for the purpose stated and that the signatures are valid. I further understand that it is my responsibility to immediately notify the DFPS in writing of any changes to the above list.

Printed or Typed Name & Title of Contract Signatory Signature

Page 1 of 1

Texas Dept of Family and Protective Services

Disclosure and Consent to Release of Information Regarding Criminal or Abuse/Neglect History

For Applicants, Employees or Volunteers of DFPS Contractors and Subcontractors

Form 2970c August 2012

Any person who will have direct contact with a Department of Family and Protective Services (DFPS) client or access to DFPS client information must complete this form.

1. Have you ever been convicted of a felony or misdemeanor as an adult or juvenile? Thisincludes offenses to which you pleaded guilty or no contest resulting in a deferred adjudication.that has not yet been completed. Yes No

If yes, give details including date, location and nature of the offense and disposition for eachsuch incident.

2. Are you currently charged with (indictment or official criminal complaints by county or districtcourt) a felony or misdemeanor? Yes No

If yes, give details, including date, location, and type of charge.

3. Have you been or are you currently being investigated for allegedly abusing, neglecting, orexploiting a child, an elderly person, or a person with disabilities? Yes No

If yes, give details, including the state and county in which each such investigation occurred.

I declare that the information provided on this statement is true and correct. I understand that any misrepresentation or omission of the information requested may result in my being barred from providing direct services or accessing DFPS client records under a contract with DFPS.

I also agree to inform the contractor, who will in turn notify the DFPS contract manager, if I am named in complaints, indictments, or convictions of offenses as described in items 1 & 2, or if I am investigated for allegations as described in item 3 of this form.

I grant permission to this contractor to request a DFPS Abuse/Neglect check, a Texas Department of Public Safety criminal history check, and (if applicable) a Federal Bureau of Investigation criminal history check using my identifying information.

I consent to DFPS’ disclosure of any and all information, including confidential information, obtained from the above-referenced sources to the contractor listed below in order to facilitate my employment, subcontracting, or volunteer service with such contractor.

Printed Name of Person Completing Form Signature of Person Completing Form

Date Signed Contractor’s Name Contract #

Additional pages can be attached, as necessary.

Form J-800-2971 Revised August 2016

Page 1 of 6

CHILD CARE LICENSING REQUEST FOR BACKGROUND CHECK

Purpose: Use this form to submit a background check for individuals required by Texas Administrative Code (TAC)

§745.615.

Directions: Complete the following information for each person required to have a background check. Additional forms may be downloaded from the DFPS website at http://www.dfps.state.tx.us/Child_Care/Information_for_Providers/cclforms.asp.

After completing this form, you may fax this form to 512-339-5871 or mail it to: DFPS, Centralized Background Check

Unit, P.O. Box 149030, Mail Code: 121-7, Austin, TX 78714-9030.

OPERATION INFORMATION

Operation Name: Operation Number: Operation Telephone Number:

( ) -

Operation Address: Operation Mailing Address: County:

VERIFICATION SIGNATURES

I verified (by reviewing the person’s social security card or driver license) that the information on this form

contains no willful misrepresentation, and that the information given is true and complete to the best of my

knowledge. I understand that DFPS may contact others and, at any time, seek proof of any information contained here. I understand that any willful misrepresentation or failure to provide identifying information within the stated time limit is a cause for denial of the application or revocation of my license, registration or listing.

Printed Name of Director, Owner, or

Operator:

Signature of Director, Owner, or

Operator:

X

Date Signed:

Form J-800-2971 Revised August 2016

Page 2 of 6

INDIVIDUAL'S IDENTIFYING INFORMATION

First Name: Middle Name: Last Name:

List any other names the individual uses or has used in the past, including married and maiden names below. If you

do not provide every name that the individual has used, you may receive inaccurate results:

Other First Names: Other Middle Names: Other Last Names:

Street Address: City: State: Zip Code:

County: Telephone Number:

( ) -

Date of Birth: Gender:

Male

Female

List any other city in Texas where the person has been a resident, and any addresses, including county, where the

person has lived outside of Texas in the previous five years:

Ethnicity (must accompany race):

Hispanic

Non-Hispanic

Race:

White

Black

Asian

American Indian/Alaskan Native

Native Hawaiian/ Pacific Islander

Social Security Number: Photo ID Type:

Driver License:

Number: State:

State ID:

Date Hired or Used by the Operation or Agency:

Initial 24 Month Check Fingerprint Check Required FBI Results in DPS

Clearinghouse

Contact information is required to schedule a fingerprint appointment. You must select one of the following choices

and provide either an email address or phone number for the individual.

Preferred method of contact for scheduling fingerprint appointment:

Email:

Telephone Number: ( ) -

Relationship of person to requestor:

Adoptive Parent

Other Staff

Caregiver

Staff

Director

Volunteer

Foster Parent

Other:

Household

Member

Licensed

Administrator

For Foster/Adoptive Homes only: Relationship between child/children to be placed and the foster/adoptive parent(s) or

prospective foster/adoptive parent(s)

Relative Fictive Kin Unrelated

DFPS USE ONLY

Worker Name (Last, First): Mail code:

Form J-800-2971 Revised August 2016

Page 3 of 6

PRIVACY STATEMENT

DFPS values your privacy. For more information, read our privacy policy online at: www.dfps.state.tx.us/policies/privacy.asp.

The following pages are additional Individual's Identifying Information sheets for use when

submitting more than one individual's background check.

Form J-800-2971 Revised August 2016

Page 4 of 6

INDIVIDUAL'S IDENTIFYING INFORMATION

First Name: Middle Name: Last Name:

List any other names the individual uses or has used in the past, including married and maiden names below. If you

do not provide every name that the individual has used, you may receive inaccurate results:

Other First Names: Other Middle Names: Other Last Names:

Street Address: City: State: Zip Code:

County: Telephone Number:

( ) -

Date of Birth: Gender:

Male

Female

List any other city in Texas where the person has been a resident, and any addresses, including county, where the

person has lived outside of Texas in the previous five years:

Ethnicity (must accompany race):

Hispanic

Non-Hispanic

Race:

White

Black

Asian

American Indian/Alaskan Native

Native Hawaiian/ Pacific Islander

Social Security Number: Photo ID Type:

Driver License:

Number: State:

State ID:

Date Hired or Used by the Operation or Agency:

Initial 24 Month Check Fingerprint Check Required FBI Results in DPS

Clearinghouse

Contact information is required to schedule a fingerprint appointment. You must select one of the following choices

and provide either an email address or phone number for the individual.

Preferred method of contact for scheduling fingerprint appointment:

Email:

Telephone Number: ( ) -

Relationship of person to requestor:

Adoptive Parent

Other Staff

Caregiver

Staff

Director

Volunteer

Foster Parent

Other:

Household

Member

Licensed

Administrator

For Foster/Adoptive Homes only: Relationship between child/children to be placed and the foster/adoptive parent(s) or

prospective foster/adoptive parent(s)

Relative Fictive Kin Unrelated

Form J-800-2971 Revised August 2016

Page 5 of 6

INDIVIDUAL'S IDENTIFYING INFORMATION

First Name: Middle Name: Last Name:

List any other names the individual uses or has used in the past, including married and maiden names below. If you

do not provide every name that the individual has used, you may receive inaccurate results:

Other First Names: Other Middle Names: Other Last Names:

Street Address: City: State: Zip Code:

County: Telephone Number:

( ) -

Date of Birth: Gender:

Male

Female

List any other city in Texas where the person has been a resident, and any addresses, including county, where the

person has lived outside of Texas in the previous five years:

Ethnicity (must accompany race):

Hispanic

Non-Hispanic

Race:

White

Black

Asian

American Indian/Alaskan Native

Native Hawaiian/ Pacific Islander

Social Security Number: Photo ID Type:

Driver License:

Number: State:

State ID:

Date Hired or Used by the Operation or Agency:

Initial 24 Month Check Fingerprint Check Required FBI Results in DPS

Clearinghouse

Contact information is required to schedule a fingerprint appointment. You must select one of the following choices

and provide either an email address or phone number for the individual.

Preferred method of contact for scheduling fingerprint appointment:

Email:

Telephone Number: ( ) -

Relationship of person to requestor:

Adoptive Parent

Other Staff

Caregiver

Staff

Director

Volunteer

Foster Parent

Other:

Household

Member

Licensed

Administrator

For Foster/Adoptive Homes only: Relationship between child/children to be placed and the foster/adoptive parent(s) or

prospective foster/adoptive parent(s)

Relative Fictive Kin Unrelated

Form J-800-2971 Revised August 2016

Page 6 of 6

INDIVIDUAL'S IDENTIFYING INFORMATION

First Name:

Middle Name:

Last Name:

List any other names the individual uses or has used in the past, including married and maiden names below. If you

do not provide every name that the individual has used, you may receive inaccurate results:

Other First Names:

Other Middle Names:

Other Last Names:

Street Address:

City:

State:

Zip Code:

County:

Telephone Number:

( ) -

Date of Birth:

Gender:

Male

Female

List any other city in Texas where the person has been a resident, and any addresses, including county, where the

person has lived outside of Texas in the previous five years:

Ethnicity (must accompany race):

Hispanic

Non-Hispanic

Race:

White

Black

Asian

American Indian/Alaskan Native

Native Hawaiian/ Pacific Islander

Social Security Number:

Photo ID Type:

Driver License:

Number: State:

State ID:

Date Hired or Used by the Operation or Agency:

Initial 24 Month Check Fingerprint Check Required FBI Results in DPS

Clearinghouse

Contact information is required to schedule a fingerprint appointment. You must select one of the following choices

and provide either an email address or phone number for the individual.

Preferred method of contact for scheduling fingerprint appointment:

Email:

Telephone Number: ( ) -

Relationship of person to requestor:

Adoptive Parent

Other Staff

Caregiver

Staff

Director

Volunteer

Foster Parent

Other:

Household

Member

Licensed

Administrator

For Foster/Adoptive Homes only: Relationship between child/children to be placed and the foster/adoptive parent(s) or

prospective foster/adoptive parent(s)

Relative Fictive Kin Unrelated

74-176 (Rev.1-11/10)

Vendor Direct Deposit / Advance Payment Notifi cation Authorization This form may be used by vendors or individual recipients

- to receive payments from the state of Texas by direct deposit - to change or cancel existing direct deposit information

Transaction Type

For Comptroller’s Use Only

For State Agency Use

Advance Payment Notification

International Payments Verification

Interagency Transfer

SE

CT

ION

1

New setup (Sections 2, 3, 4 and 5 - Section 6 is optional) Change account type (Sections 2, 3, 4 and 5 - Section 6 is optional)

Change fi nancial institution (Sections 2, 3, 4 and 5 - Section 6 is optional) Cancellation (Sections 2 and 4 - Sections 7 and 8 for state agency use)

Change account number (Sections 2, 3, 4 and 5 - Section 6 is optional)

Payee Identification

Social Security Number (SSN) or Mail code Employer Identification Number (EIN) (If not known, leave blank.)

Payee name (Business/Individual) Phone number

Mailing address City State ZIP code SE

CT

ION

2

( ) ext.

Financial Institution (Completion by financial institution is recommended.) Financial institution name City State

Routing transit number (9 digits) Customer account number (maximum 17 characters) Type of account

Checking Savings

Financial representative name (optional) Title (optional)

Financial representative signature (optional) Phone number (optional) Date (optional)

SE

CT

ION

3

( ) ext.

Authorization for Setup, Changes or Cancellation (required)

SE

CT

ION

4

Authorized signature Printed name Date

I authorize the Texas Comptroller of Public Accounts to deposit my payments from the state of Texas to my financial institution electronically. I understand that the Texas Comptroller of Public Accounts will reverse any payments made to my account in error.

I further understand that the Texas Comptroller of Public Accounts will comply at all times with the National Automated Clearing House Association's rules. (For further information on these rules, please contact your fi nancial institution.)

International Payments Verification (required)

SE

C 5

Will these payments be forwarded to a financial institution outside the United States? ......................................................... YES NO

Authorization for Advance Payment Notifi cation Setup (optional)

SE

CT

ION

6

I authorize the Texas Comptroller of Public Accounts to send an e-mail notification one business day prior to the payment posting to my account. I understand that notifications may include payment information that is considered confidential and therefore exempt from public disclosure.

Contact name (Please print) Contact phone number

( ) ext.

E-mail address

Cancellation by Agency (for state agency use)

SE

C 7 Reason Date

Authorized Signature (for state agency use) Signature Date

Phone number Agency number

Agency name

Comments

SE

CT

ION

8

( ) ext.

TEXAS COMPTROLLER OF PUBLIC ACCOUNTS Fiscal Management - Direct Deposit Program P.O. Box 13528 Austin, TX 78711-3528

E-mail: claims.pin@cpa.state.tx.us FAX: (512) 475-5424 Phone: (512) 936-8138

Please return your completed form to:

Form 74-176 (Back)(Rev.1-11/10)

Instructions for Vendor Direct Deposit / Advance Payment Notification Authorization

Under Ch. 559, Government Code, you are entitled to review, request and correct information we have on file about you, with limited exception in accordance with Ch. 552, Government Code. To request information for review or to request error correction, contact us at (800) 531-5441, ext. 6-6057.

Section 1: Select the appropriate transaction type(s).

Section 2: Provide the Social Security Number or Employer Identification Number (EIN).

Section 3: Completion by financial institution is recommended. Important: Your direct deposit account information may be different from the account information printed on your checks. It is recommended that you contact your financial institution to confirm your direct deposit account information.

Note: A prenote test will be sent to your financial institution for the account information entered into the Comptroller's system. The prenote test is for a period of six banking days, and it is sent to your financial institution to verify your account information. If no further action is required by your financial institution, your direct deposit instructions will become effective when the six banking day prenote time frame has expired.

Section 4: Must be completed in its entirety, and no alterations to the authorization language will be accepted.

Section 5: If you receive state payments by direct deposit which are forwarded from a United States financial institution to a financial institution outside the United States, please contact the Texas Comptroller of Public Accounts at (512) 936-8138 and FAX your form to (512) 475-5424 or send to tins.mail@cpa.state.tx.us.

Section 6: Provide the contact name, phone number and e-mail address to which payment notifications are to be sent. Notifications are sent for direct deposit payments only, and e-mails are sent one business day prior to the deposit.

Submit the completed form to the state agency with which you are conducting business. If the agency is unknown, please call (512) 936-8138 to obtain contact information.

For State Agency Use

Section 7: Provide reason for cancellation request.

Section 8: Must be completed if submitting form to the Comptroller's office for international payment verification, advance payment notification or interagency transfer processing. Indicate requested action using the "For State Agency Use" box located at the top of the form.

If an international payments verification, advance payment notification or interagency transfer is requested by the agency, select the desired action(s) in the box on the upper right corner of the form and submit the form to the Comptroller's office. State agencies should complete the direct deposit setup or change prior to submitting the form to the Comptroller's office.

TEXAS DEPARTMENT OF FAMILY AND PROTECTIVE SERVICES APPLICATION FOR TEXAS IDENTIFICATION NUMBER /

ADDITIONAL MAILING ADDRESS

Form 4109X Jan 2002

Doc. Type Doc . No. ISAS Update Only

Th is app l i ca t ion mus t be subm i t ted by every person (so le owner , ind iv i dua l rec ip ient , par t ne rsh ip , co rpo ra t ion , or o the r organ i zat i on ) who in t ends t o b i l l t he Texas Depar tment o f Fam i ly and Pro tec t i ve Serv ices for goods , serv ic es prov ided, re funds , pub l i c ass is tance, e tc .

Your Texas Ident i f i ca t i on No. (T I N) wi l l be requ i red on a l l vouchers subm i t ted by any s ta t e agency. Your use o f th is T IN on a l l b i l l i ngs wi l l r educe the t ime requ i red to p rocess your b i l l i ngs to the S t a te o f Texas .

For ass is tance i n comple t ing th is app l i ca t i on , ca l l the FPS Account ing Di v is i on a t (512) 438-2401.

• P lease DO NOT wr i te i n shaded boxes ( t hese areas a re fo r Account ing Di v is ion use) . • P lease DO NOT use dashes when ente r ing Soc ia l Sec ur i t y , Federa l Employe r ’s Ident i f i ca t i on (FEI ) , o r

Compt ro l l e r ’ s ass igned numbers . • D isc losure o f you r Soc ia l Secur i t y No. i s autho r i zed under the l aw (Op. Tex. A t t ’ y . , Gen. No. H-1225 [1978] ) . • P lease TYPE or PRINT a l l en t r i es .

New Account ( in i t ia l se t up ) Mai l Code Yes (Ma i l Code 000) No

I. TEXAS IDENTIFICATION NUMBER - The number you provide in this section will be used to report payments to the IRS, if applicable.

Ind ica te t ype o f number you are prov id i ng to be used for you r T IN by check ing the appropr ia te box be low:

1 - F e d e ra l E m p l o ye r ’ s I d en t i f i c a t i o n ( FE I ) N o . 3 - C om p t r o l l e r ’ s as s i g ne d n um b e r Enter the number :

2 - S oc i a l S ec u r i t y N um b er Check box i f agenc y representa t i ve to be not i f i ed o f ass igned T IN by mai l a t mai l code ente red in Sec t ion V I I I . II. PAYEE INFORMATION - (maximum 50 characters, including spaces, per line in this section.) Name of Payee ( i nd i v i dua l or bus iness to be pa id)

Mai l ing Address (where you want to rece ive payment s )

2nd L ine Address ( i f requ i red)

3 rd L ine Address ( i f r equ i red)

4 th L i ne Address ( i f r equ i red)

C i t y S ta te Z ip + 4 County

Bus iness Te lephone No. A /C and Number S IC Code Secur i t y Type Zone (area code and number ) : 0 1 2

A re you cu r rent l y repo r t ing any Texas tax o the r I f “Yes ” , ente r Texas Taxpayer No. than unemployment (E .G. , sa les tax, f ranch ise tax)? Yes No

I I I . BUSINESS INFORM ATION ( for s ta t ist i cal report ing) - P lease check a l l ca tegor i es that appl y to your business. PROVIDING THE INFORMATI ON REQUESTED IN THIS SECTION IS VOLUNTARY.

Smal l Bus iness Enterpr is e ( independent ly owned and operat ed wi th fewer t han 100 employees or l ess than $1,000,000 annual g ross rece ip ts )

D isadvantaged Bus iness Enterp r ise (a t leas t 51% owned o r cont ro l led by one or more soc ia l l y d isadvantaged persons) - Check the appropr ia te ca tego ry :

B l ack H i s pa n i c A m e r i c a n I n d i an A s i a n A m e r i ca n E sk i m o A l eu t O t he r ( s p ec i f y ) ;

W oman Owned Bus iness Enterp r ise (a t leas t 51% owned o r cont ro l led by women)

Other Bus iness Enterpr is e (an ent erpr ise not desc r i bed i n one o f the t hree cat ego r ies shown above) F P S U S E O N L Y

B u s . D e s c .

Form 4109X Page 2

IV . OW NERSHIP CODES (For In i t ia l Set -up onl y) - Check ONLY ONE code b y the appropr ia te ownershi p t ype tha t

appl ies to you or your business and en ter an y requi red addi t ional in format i on.

I - I nd i v idua l Rec ip ient (no t owning a bus iness ) Agency No.

E-S ta t e Employee - Ente r agency number o f employ ing agenc y:

S-So le Ownersh ip o f Bus iness - Enter owner ’s name and Soc ia l Secur i t y No.

Owner ’s Name Soc ia l Secur i t y No. 2

P- Pa r tnersh ip - Ent er t wo pa r tne r ’s names and SSN’s . I f par tne r i s corpo ra t i on , use co rpo ra t i on ’s Federa l

Employer ’s Ident i f i ca t i on (FEI ) number .

Par tne r 1 - Name SSN / FEI

Par tne r 2 - Name SSN / FEI

T - Texas Corporat ion E n te r T x C h a r t e r N o . ( I f T , A , o r C i s c he ck e d )

Texas Char te r No. A- P ro fess iona l Assoc ia t i on E n te r T x C h a r t e r N o . ( I f T , A , o r C i s c he ck e d )

C - Pro fess iona l Corpora t i on E n te r T x C h a r t e r N o . ( I f T , A , o r C i s c he ck e d )

O- Out -o f -s ta t e Corpora t i on

G- Government Ent i t y

U- S ta te Agency / Un i ve rs i t y

F - F inanc ia l Ins t i tu t i on

R- Fo re ign (out o f U.S .A . )

N- Other (exp la in ) :

V. PAYMENT ASSIGNMENT INFORM ATION (NOTE: A copy of the assignment agreement between payees must be attached.) Ass ignee Name Ass ignee T IN Ass ignment Date VI . COMMENTS:

VI I . APPLIC ANT I NFORMATI ON App l i cant or Author ized Agent Telephone No. (inc. A/C) Date

VI I I . FPS REPRESENTATIVE INFORM ATION FPS Represent a t i ve Telephone No. (inc. A/C) FPS Mai l Code

Certificate of Insurance Form 4736

August 2012

Agents are required to complete this Certificate of Insurance (Certificate) by providing all requested information. Copies of endorsements listed below are not required as attachments to this Certificate.

This Certificate is issued as a matter of information only and confers no rights upon this Certificate's holder, the Texas Department of Family and Protective Services (DFPS). The information provided by the Authorized Insurance Representative in this Certificate does not control over the terms in the policies issued by the Insurer.

Insured:

Street/Mailing Address:

City/State/Zip:

Telephone number:

COMMERCIAL GENERAL LIABILITY INSURANCE Insurer Name: Insurer Telephone: Address: City/State/Zip:

Type of Insurance Policy Number Effective Date Expiration Date Limits of Liability

Occurrence/Aggregate Commercial General Liability Insurance

Sexual Abuse & Molestation

COMMERCIAL CRIME INSURANCE Including a third party and employee dishonesty endorsements Insurer Name: Insurer Telephone: Address: City/State/Zip:

Type of Insurance Policy Number Effective Date Expiration Date Limits of Liability Occurrence/Aggregate

Commercial Crime Insurance

BUSINESS AUTOMOBILE LIABILITY INSURANCE Including owned, hired, and non-owned vehicles Insurer Name: Insurer Telephone: Address: City/State/Zip:

Type of Insurance Policy Number Effective Date Expiration Date Limits of Liability

Occurrence/Aggregate Business Automobile Liability Insurance

PROFESSIONAL LIABILITY INSURANCE Insurer Name: Insurer Telephone: Address: City/State/Zip:

Type of Insurance Policy Number Effective Date Expiration Date Limits of Liability

Occurrence/Aggregate Professional Liability Insurance

General Liability Coverage

Should any of the above described policies be cancelled before the policy's expiration date, notice will be delivered to DFPS in accordance with the policy provision.

Certificate of Insurance Form 4736

August 2012 BY SIGNING THIS CERTIFICATE OF INSURANCE, THE UNDERSIGNED CERTIFIES to DFPS acting on behalf of the State of Texas that the insurance policies named are in full force and effect. If this Certificate is sent by facsimile machine (fax), the sender adopts the certificate received by DFPS as a duplicate original and adopts the signature produced by the receiving fax machine as the sender’s original signature.

Agency Name:

Authorized Insurance Representative:

Address:

City/State/Zip:

Telephone Number: ____________________________________________ ________________________ Authorized Insurance Representative Date

INSTRUCTIONS TO AGENTS

1. Agents must provide all requested information on this Certificate. 2. Binder numbers are not acceptable for policy numbers. 3. This Certificate acts as the only acceptable proof of insurance coverage required for DFPS contracts. 4. List the Insured’s legal name, including the DBA (doing business as) name. Over-stamping and/or over-typing

entries on this Certificate are not acceptable if such entries change any of the provisions of this Certificate. 5. IF APPLICABLE, DO NOT COMPLETE THIS CERTIFICATE UNLESS THE BUSINESS AUTOMOBILE

LIABILITY POLICY INCLUDES OWNED VEHICLES, HIRED VEHICLES, AND NON-OWNED VEHICLES. 6. DO NOT COMPLETE THIS CERTIFICATE UNLESS THE COMMERCIAL CRIME POLICY INCLUDES A THIRD

PARTY AND EMPLOYEE DISHONESTY ENDORSEMENT.

Contracting Entity and List of Staff, Subcontractors and VolunteersSubstance Abuse Services

PCS-102SUDJune 2013

Contract or Procurement Number

Email

Requested Date Expiration Date Crime Policy

Expiration DateCurrentBondEffectiveDate

Expiration Date

License Type

[Attach Copy]

License

Expiration DateListLanguages[OtherthanEnglish]

ListModalities TraditionalMedicaid #

MCO

ID # Enter Contractor Name Here

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

Professional Liability

Insurance

Direct Provider Primary Service

Type

Dir

ect

Pro

vide

r

Vol

unte

er

Sub

cont

ract

or

Background Check

Role: Check All that Apply

Region

Commercial General

Workplace Liability

DishonestyBond

Legal Entity

Fiscal Year

List contracting entity and all names(s) of key personnel, staff, subcontractors and volunteers working under this contract.

Contracting Entity on 1st Line/

Staff/Subcontractor/Volunteer NameEnsure individual names are in Title Format: Last, First

If Supervisor, Include Supervisor after NameExample: Smith, John PHD (Supervisor) or AAA Counseling

Crime Policy

Professional License MedicaidLanguage(s)

Em

ploy

ee

TreatmentModalities

Key

Per

sonn

el

Off

-Sit

e S

ervi

ces

1 of 2

Contracting Entity and List of Staff, Subcontractors and VolunteersSubstance Abuse Services

PCS-102SUDJune 2013

Contract or Procurement Number

Email

Requested Date Expiration Date Crime Policy

Expiration DateCurrentBondEffectiveDate

Expiration Date

License Type

[Attach Copy]

License

Expiration DateListLanguages[OtherthanEnglish]

ListModalities TraditionalMedicaid #

MCO

Professional Liability

Insurance

Direct Provider Primary Service

Type

Dir

ect

Pro

vide

r

Vol

unte

er

Sub

cont

ract

or

Background Check

Role: Check All that Apply

Region

Commercial General

Workplace Liability

DishonestyBond

Legal Entity

Fiscal Year

List contracting entity and all names(s) of key personnel, staff, subcontractors and volunteers working under this contract.

Contracting Entity on 1st Line/

Staff/Subcontractor/Volunteer NameEnsure individual names are in Title Format: Last, First

If Supervisor, Include Supervisor after NameExample: Smith, John PHD (Supervisor) or AAA Counseling

Crime Policy

Professional License MedicaidLanguage(s)

Em

ploy

ee

TreatmentModalities

Key

Per

sonn

el

Off

-Sit

e S

ervi

ces

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I certify that as of the Acknowledgment Date this list accurately represents the persons working under this contract and that all applicable credentials including insurance for persons working under this contract are current and on file. Furthermore, I understand that I must report any new persons associated with this contract to the DFPS Contract Manager using Form PCS-102SUD and obtain written approval prior to their providing services or accessing client information. Form PCS-102SUD is located at http://www.dfps.state.tx.us/PCS/Regional_Contracts/forms.asp. I also understand that I must submit a background check through ABCS initially for each person and every 24 months thereafter.

Contract Manager Approval

Approval Exceptions:The service providers (identified by ID #) listed below have not been approved to work under this contract.

Approval Date

Acknowledgment DateContracting Entity Signatory

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