Risk Analysis Questionnaire

Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 42 CONTRACTOR INFORMATION 1. Information About Proposing Organization or Individual Full Legal Name of Organization, Agency or Individual Mailing Address (Street/P.O. Box, City, State, and Zip Code) Physical Address (Street, City, State, and Zip Code) Contact Person* (Name/Title) Contact Telephone Number Alternate Contact Number *This person must be able to answer questions regarding this contract. 2. Legal Status Information Check boxes as they apply to your organization, and complete information as applicable. Public Agency If Public Agency: Private Corporation Partnership Yes Sole Proprietorship No Do you have taxing authority? State of Charter Charter Number (Attach Copy of Charter) If Private Corporation: This corporation is: For Profit If Partnership: Non-Profit Attach a copy of partnership agreement and list of names, addresses and social security numbers of all partners. Full Name and Address of Owner Social Security Number Telephone Number If Sole Proprietorship: 3. Executive Director/Officer Name Title Telephone Number 4. Program Director Name Title Telephone Number Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 43 Texas Dept of Family and Protective Services Internal Control Structure Questionnaire (ICSQ) for POS FPS Contract #: Form 9007POS September 2002 Contractor Name: Current Contract Period: Contract Manager: Please refer to instructions at the end of this questionnaire. SECTION I: FINANCIAL POSITION (This section should be answered about your organization as a whole.) 1. Please describe the accounting system in place (i.e., accrual, cash, or modified accrual) ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Do you complete yearly financial statements (e.g., Balance Sheet, Income Statement, Other)? If yes, please list the name of the person responsible for preparing the annual financial statements below and attach copy of your most “current” statements and mark it ATTACHMENT# I-2. Person responsible for annual financial statements: ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ If no, please provide any manual or automated information maintained regarding your “current” financial position (i.e., assets versus liabilities) and mark it ATTACHMENT # I-2. Yes No 2. 3. Are your accounting and financial system operations “audited” at regular intervals by an independent auditor (CPA, State Public Accountant, Office of State Auditor)? Note that this is not referring to compliance monitoring performed by State Contract Managers. If yes, how often and who audits your records? ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Also, if yes, please provide a copy of your most current “audit” performed of your agency and mark it ATTACHMENT #I-3. Yes No 4. Does your organization certify that there are no contingencies, outstanding liabilities or litigation that could affect your organization’s financial position during the life cycle of the contract (e.g., outstanding audit exceptions or purchase of real property)? If no, please explain. ___________________________________________________________ ___________________________________________________________ Yes No Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 44 ___________________________________________________________ 5. Does your organization stay current with payment of its liabilities, loans, taxes, etc.? If no, please explain, and include any defaults on loans or violations of restricting covenants in loan agreements in the past year. ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Is your organization able to obtain credit when needed? If no, please explain any difficulty your organization has had in obtaining credit in the previous year. ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ If your organization has been audited by the Internal Revenue Service (IRS) in the past two years, have all discrepancies been resolved (i.e., no major discrepancies or disputes)? If no, please describe the nature of the discrepancies or impact of the audit on your financial position. ___________________________________________________________ ___________________________________________________________ Yes No 6. Yes No 7. Yes No N/A SECTION II: INTERNAL CONTROLS II. A. GENERAL/ACCOUNTING CONTROLS (This section should be answered about your organization as a whole. When a question mentions “contracts,” it is referring to all of your contracts with FPS and with any other state agencies, as well as any grants you might have.) 1. Do you have more than one contract with FPS? If yes, please attach a list of all of your FPS contracts, including type of service, contract number, dollar amount of contract, contract payment method (e.g., cost reimbursement, budget-based unit rate, or fee-forservice), and name and telephone number of FPS contact person for each contract. Mark this list ATTACHMENT #II-1. Yes No 2. Do you have contracts with other Texas state agencies (e.g., Texas Youth Commission, Texas Juvenile Probation Commission, Texas Education Agency, etc.)? If yes, please attach a list of all your contracts with other state agencies, including the state agency name, type of service provided under the contract, dollar amount, and name and telephone number of state agency contact person for the contract. Mark this list ATTACHMENT # II-2. Yes No 3. Do you maintain contract files for each of your FPS contracts? If yes, do the contract files contain: a. The approved contract with all attachments? Yes No Yes No Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 45 b. Copies of contract amendments? c. Billing documents? d. Related correspondence? e. Copies of subcontracts? Yes No Yes Yes No No Yes No 4. a. Are all expenditures that are reported and/or billed as FPS costs reconciled with your general ledger? If no, please provide a written explanation below as to why such expenditures are not reconciled to your general ledger. Yes No ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ b. Is the general ledger kept up-to-date and balanced at least monthly? If not monthly, please specify frequency. Yes No ______________________________________________________ ______________________________________________________ ______________________________________________________ c. Are financial statements reviewed by Executive Management? If no, please explain. Yes No ______________________________________________________ ______________________________________________________ ______________________________________________________ 5. Do you maintain a separate general ledger account for: a. Deposits for each contract’s funds? .................................................................. b. Disbursement of each contract’s funds? ........................................................... Please provide a copy of your chart of accounts, along with an explanation of how your accounting system identifies contract revenues and expenditures separately for each contract. Mark it ATTACHMENT # II-5. Yes No Yes No 6. 7. Are billings submitted within the time frame specified in the FPS contract? How do you allocate shared costs between contracts and/or programs? Please attach a detailed explanation, and mark it ATTACHMENT # II-7. Yes No N/A 8. Are costs and expenditures under budgetary control for both total contract budget and by budget category (for cost reimbursement and budget-based unit rate contracts)? Yes No N/A Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 46 9. Do you authorize separate individuals to: a. Sign checks? Indicate name(s) and title(s) ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ b. Approve purchase orders and vouchers? Indicate name(s) and title(s) Yes No Yes No ______________________________________________________ ______________________________________________________ ______________________________________________________ c. Prepare checks? Indicate name(s) and title(s) Yes No ______________________________________________________ ______________________________________________________ ______________________________________________________ d. Record accounting transactions? Indicate name(s) and title(s) Yes No ______________________________________________________ ______________________________________________________ ______________________________________________________ e. Reconcile bank accounts to internal check registers? Indicate name(s) and title(s) Yes No ______________________________________________________ ______________________________________________________ ______________________________________________________ f. Maintain an inventory? Indicate name(s) and title(s) Yes No ______________________________________________________ ______________________________________________________ ______________________________________________________ Is your accounting system automated? If no, skip to Question #18. 10. 11. Yes No Who has access to the accounting system? Specify name(s) and title(s) below: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 47 12. Please specify the name(s) and title(s) below for the individuals responsible for updating, changing and deleting accounting information: Updating: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Changing: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Deleting: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ How is the accounting system secured and/or protected? Please explain. 13. ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Explain below the process (initiation, review, approval, etc.) for making updates, changes, deletions, and year end adjustments to the accounting system. 14. ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ 15. 16. Are there controls to provide reasonable assurance that transactions are not lost, duplicated, or added before and after data entry and editing? Are there controls to provide reasonable assurance that transactions with errors are rejected from further processing (e.g., prevented from updating the files/database)? Is the data entered into the accounting system verified? If yes, please specify whom (name and title) is/are responsible for verifying the data, and how the verification is done. Yes No Yes No 17. Yes No _______________________________________________________ Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 48 _______________________________________________________ _______________________________________________________ _______________________________________________________ 18. a. Do purchase orders/requisitions require specific approvals from authorized individuals in the requesting department? What additional internal controls and approvals are in place within the organization to ensure payments made are valid and authorized? Yes No N/A b. _______________________________________________________ _______________________________________________________ 19. Are all checks pre-numbered and accounted for? If no, please explain. Yes No _______________________________________________________ _______________________________________________________ _______________________________________________________ 20. Is there any additional review or special approval required for checks exceeding a specific dollar amount? If yes, please specify the dollar limits, name(s) and title(s) of responsible staff below. Yes No _______________________________________________________ _______________________________________________________ _______________________________________________________ 21. Are voided checks marked “VOID” to prevent reuse? If no, please explain. Yes No _______________________________________________________ _______________________________________________________ _______________________________________________________ 22. Are voided checks kept with canceled checks? If no, please explain. Yes No _______________________________________________________ _______________________________________________________ _______________________________________________________ 23. Are unused checks adequately safeguarded and in the custody of a person who does not manually sign checks, control the use of facsimile signature plates or operate the facsimile signature machine? Indicate name and title of person below who has custody of unused checks. Yes No _______________________________________________________ _______________________________________________________ 24. If a check -signing machine is used, are the facsimile signature plates Yes No N/A Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 49 properly safeguarded? If no, please explain below. _______________________________________________________ _______________________________________________________ _______________________________________________________ 25. Is the person receiving cash prohibited from signing checks, reconciling bank accounts, and accessing other accounting records? Indicate name and title below of person receiving cash. Yes No _______________________________________________________ _______________________________________________________ _______________________________________________________ 26. Is the drafting of checks to “CASH” prohibited? If no, please explain. Yes No _______________________________________________________ _______________________________________________________ _______________________________________________________ 27. Is the practice of signing blank checks prohibited? If no, please explain. Yes No _______________________________________________________ _______________________________________________________ _______________________________________________________ 28. Are all disbursements approved prior to payment? If no, please explain. Yes No _______________________________________________________ _______________________________________________________ _______________________________________________________ 29. Are all disbursements (excluding petty cash) made by check? If no, what other means do you use to make disbursements? Yes No _______________________________________________________ _______________________________________________________ _______________________________________________________ Is a check register (disbursement journal) used to record disbursements and maintain balances? If no, how are disbursements and balances tracked? Yes No _______________________________________________________ _______________________________________________________ _______________________________________________________ 30. Are purchase orders/requisitions controlled in such a way that they can all be accounted for (e.g., by sequential pre-numbering, by entry in a register, etc.)? If yes, please attach an explanation and mark it ATTACHMENT # II-30. Yes No N/A 31. Are supporting documents (invoices, receipts, approvals, receiving reports, canceled checks, etc.) maintained with each disbursement and/or clearly Yes No Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 50 referenced for easy location and retrieval? Please comment on where and how supporting records are kept and filed (e.g., filed by check number, month of payment, etc). _______________________________________________________ _______________________________________________________ _______________________________________________________ 32. 33. 34. 35. Do supporting documents accompany checks for the check signer’s signature? Are supporting documents marked when paid to prevent reuse or duplication of payment? Are invoices marked to identify allocation of payment? For your FPS contracts, do you have procedures to identify costs and expenditures not allowable under federal and/or state regulations? If so, please attach an explanation of your system for identifying unallowable costs/expenditures and mark it ATTACHMENT # II-35. Yes No Yes No Yes Yes No No 36. Are all bank accounts reconciled monthly? If not, how often? Yes No _______________________________________________________ _______________________________________________________ 37. 38. If bank account balances (including Certificates of Deposit) are in excess of FDIC coverage, has the bank pledged securities? Do you have a fidelity bond (of at least $10,000) on employees in appropriate positions (e.g., employees handling cash, employees responsible for equipment inventory)? Indicate name(s) and title(s) of employees covered. ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Do you maintain commercial general liability insurance coverage (with a minimum coverage per occurrence of $500,000, and a minimum aggregate coverage of $1,000,000)? Is insurance coverage (fire, theft, flood) maintained at amounts sufficient to cover the value of all the assets (building, equipment, personal property)? Yes No N/A Yes No 39. Yes No N/A 40. Yes No II. B. PERSONNEL 41. Do you have on file authorizations covering rates of pay, withholding and deductions for each employee? If no, please explain. ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Yes No N/A Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 51 42. Do any employees work overtime? If yes, please attach a copy of your overtime policy and mark it ATTACHMENT#II-42. Yes No N/A 43. Do you have written job descriptions with set salary levels for each employee? If no, please explain. Yes No N/A _______________________________________________________ _______________________________________________________ _______________________________________________________ 44. Does your policy require individual daily time and attendance records for personnel (part-time, full-time, and/or in-kind volunteers) delivering services under your FPS contract(s)? If no, please explain. Yes No N/A _______________________________________________________ _______________________________________________________ _______________________________________________________ If yes, do the time and attendance records contain the following: a. Employee’s name? ..................................................................................... b. Position/title? .............................................................................................. c. Total daily hours worked? ........................................................................... d. Daily hours charged directly to each contract? ........................................... e. Employee’s signature and/or supervisor’s signature? ................................. Yes No Yes No Yes Yes Yes Yes No No No No N/A 45. a. Are you current with your payroll taxes? b. Do you pay taxes directly? If no, please explain and indicate name of withholding agent. Yes No N/A _______________________________________________________ _______________________________________________________ _______________________________________________________ 46. Do you have written personnel policies? ......................................................... If yes, are they distributed to all employees? ................................................... Do your personnel policies include: a. Hiring policies? ............................................................................................. b. Performance evaluations? ............................................................................ Yes No N/A Yes No N/A Yes No Yes No Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 52 c. Termination policies?.................................................................................... d. Vacation and/or other authorized absences? ................................................ e. Possible conflict of interest? ......................................................................... f. Nepotism policies? ....................................................................................... g. Related-party policies? ................................................................................. Yes No Yes No Yes Yes No No Yes No 47. a. For FPS cost reimbursement contracts and budget-based unit rate contracts, does the amount of salary being paid to each employee agree with the approved budget? b. If only a portion of any employee’s salary is charged to FPS (i.e., allocated) is that portion supported by an allowable and equitable allocation method? If yes, please explain allocation method(s) used. ____________________________________________________________ ________________________________________________________ Yes No N/A Yes No N/A _______________________________________________________ II. C. TRAVEL 48. Are expenditures for travel substantiated by travel vouchers, travel logs and/or other supporting documentation? If yes, do travel vouchers/logs contain the following information: a. Name of employee? .................................................................................... b. Travel destination (to and from) ................................................................... c. Private car mileage? (to and from destination for each trip) ....................... d. Date and time of departure and return? ....................................................... e. Purpose of trip? ........................................................................................... f. Signature of employee? ............................................................................... g. Approval of supervisor? ......................................................................... Yes No Yes No N/A Yes Yes No No Yes Yes Yes No No No Yes No 49. Are travel expenditures billed to FPS at or below the prescribed State reimbursement rates? If no, please explain. Yes No N/A ______________________________________________________ Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 53 ______________________________________________________ ______________________________________________________ 50. Is out-of-state travel for FPS projects approved by the FPS contract manager? Yes No N/A II. D. EQUIPMENT (If your agency as a whole does not purchase equipment with federal funds, skip to Section II E and mark here N/A) 51. 52. Has equipment been directly purchased with FPS funds? Yes No Please specify the level of capitalization used by your organization, and provide the definition of what your organization classifies as equipment. Dollar Amount: _________________________ Definition of Equipment: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ 53. For any equipment items costing more than the level of capitalization stated above in #52 and billed to FPS, did you obtain written approval from your FPS contract manager? For any equipment items costing $5,000 or more and billed to FPS, did you obtain written approval from your FPS contract manager? Were all of the equipment items purchased and billed to FPS included in your FPS budget? If no, please list the equipment below, and include total acquisition cost. Yes No N/A 54. 55. Yes No N/A Yes No N/A ______________________________________________________ ______________________________________________________ ______________________________________________________ 56. For equipment that was directly purchased and billed to FPS, but not detailed in the budget, was prior written approval obtained from your FPS contract manager? Are all equipment items, purchased with FPS funds, tagged for the purpose of internal tracking and inventorying? Note: Since the equipment does not belong to FPS, contractors are not to tag the equipment as “State of Texas” or “FPS Property”. Yes No N/A 57. Yes No N/A 58. Do you conduct a physical inventory of capital equipment acquired with federal funds? If yes, how often? Yes No N/A ______________________________________________________ Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 54 ______________________________________________________ 59. Are inventory records maintained to include: the description of the item, the serial number, funding source, the acquisition cost, the acquisition date and the inventory number? Attach a copy of your inventory records for equipment purchases made with FPS funds and mark it ATTACHMENT # II-59. Yes No N/A 60. Has any equipment purchased in whole or in part with FPS funds been disposed of? If yes, was the FPS contract manager’s approval obtained? Yes Yes No No N/A N/A 61. a. Is equipment purchased with FPS funds being used by employees paid with FPS funds? If no, please explain. Yes No N/A ______________________________________________________ ______________________________________________________ ______________________________________________________ b. Is equipment purchased with FPS funds being used as outlined in the contract? If no, please explain. Yes No N/A ______________________________________________________ ______________________________________________________ ______________________________________________________ II. E. SUBCONTRACTORS (If your agency as a whole does not utilize subcontractors, skip to Section II F and mark here N/A) 62. 63. Do you subcontract FPS contracted services? Do you maintain written contracts with all your subcontractors? If no, please explain. ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Yes Yes No No N/A N/A 64. Within your organization, who is responsible for reviewing and approving subcontracts, prior to execution? Provide name(s) and title(s) below. ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ 65. Does each subcontract agreement include: a. All parties to the contract? .......................................................................... b. Scope of work?........................................................................................... Yes Yes No No N/A N/A Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 55 c. When services are to be performed? .......................................................... d. Rate of pay? ............................................................................................... e. Measurable method of payment? ............................................................... f. Termination clause? ............................................................................. g. Performance measures? ............................................................................ Yes Yes Yes Yes Yes No No No No No N/A N/A N/A N/A N/A 66. Do all your subcontracts for services under your FPS contract(s) (e.g., direct services to clients) either include the terms required by your FPS contract or reference the required terms? If no, please explain. ____________________________________________________________ ____________________________________________________________ ______________________________ Please attach a copy of your subcontract agreement and mark it ATTACHMENT #II-66. Yes No N/A 67. Do you have procedures in place to monitor that services under your FPS contract(s) are being delivered and paid by subcontractors as required by your FPS contract(s)? If yes, please attach a copy of your service monitoring procedures and mark it ATTACHMENT # II-67. Yes No N/A 68. a. Do you competitively procure your subcontractors? b. If you subcontract with related parties, are the contracts procured fairly? c. If you have any FPS contracts for $100,000 or more, do you make a good faith effort to subcontract with Historically Underutilized Businesses (HUBS)? In no or n/a, please explain. ____________________________________________________________ ____________________________________________________________ Please attach an explanation of your subcontractor procurement policies and procedures and mark it ATTACHMENT # II-68. Yes No N/A Yes No N/A Yes No N/A 69. Have all subcontracts for services under your FPS contract (e.g., direct services to clients) been approved by your FPS contract manager? Yes No N/A II. F. RELATED-PARTY TRANSACTIONS 70. List name and position of any employee of your corporation who is also a principal stockholder, owning 5% or more stock or who has a controlling interest. N/A _______________________________________________________ _______________________________________________________ Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 56 _______________________________________________________ _______________________________________________________ The following questions relate to “doing business” with someone. “Doing business” refers to business activities such as purchasing (e.g., a building, a computer, a vehicle, etc.), leasing (e.g., a building, a computer, a vehicle, etc.), and/or providing a service (e.g., legal services, accounting services, banking services, etc.), even if the purchase/lease/service is provided for free. 71. List any members of your Board of Directors with whom you are “doing business”. (Provide name and their position on the Board.) N/A _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ 72. List anyone with whom you are “doing business” who is related, by blood or marriage, to a member of your Board of Directors. (Provide name and their relationship.) N/A _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ 73. List anyone with whom you are “doing business” who is a principal stockholder of your organization. (Provide name and specify the relatedparty transaction.) N/A _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ 74. List anyone with whom you are “doing business” who is related, by blood or marriage, to a principal stockholder. (Provide name and specify relatedparty transaction.) N/A _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ 75. List any building and/or property leased from any related party (i.e., a member of your Board of Directors, a principal stockholder, or anyone related, by blood or marriage, to a principal stockholder or Board of Directors. (Include name of related party and specify relationship.) N/A _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ If there are items listed above, please include a copy of the lease for Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 57 each item and mark them ATTACHMENT # II-75. The following questions relate to “conflict of interest.” Key employees (e.g., executive director, president, chief executive officer, administrator, etc.) exert a degree of control. 76. List any key employees with whom you are “doing business”. (Provide name and position of employee.) N/A _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ 77. List anyone with whom you are “doing business” who is related, by blood or marriage, to any key employee. (Provide name, identify key employee, and specify business activity.) N/A _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ 78. List any building and/or property leased from a key employee. (Include name and position of employee.) N/A _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ If there are items listed above, please include a copy of the lease for each item and mark them ATTACHMENT # II-78. 79. 80. Do you maintain independent appraisals of market value or market rental rates for property resulting from related-party transactions? List any key employees related, by blood or marriage, to a member of your Board of Directors. (Provide name and position of key employee, specify relationship to member of Board of Directors and specify Board position of Board member.) ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ List any key employees related, by blood or marriage, to anyone related, by blood or marriage, to a member of your Board of Directors. (Provide name and position of key employee, specify relationship to member of Board of Directors and specify Board position of Board member.) Yes No N/A N/A 81. N/A _______________________________________________________ _______________________________________________________ _______________________________________________________ Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 58 _______________________________________________________ 82. List any key employees related by blood or marriage to a principal stockholder or to anyone related by blood or marriage to a principal stockholder. (Provide name of key employee and their position, and specify relationship.) N/A _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ 83. List any employees related by blood or marriage to a key employee or to anyone related by blood or marriage to a key employee. (Provide name and position of employees and specify the relationship.) N/A _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ CERTIFICATION Signed by an individual legally responsible for the conduct of the contractor, such as a corporate officer, an association officer, or a government official. The administrator/director is authorized to sign only if he/she holds one of these positions. I HEREBY CERTIFY, TO THE BEST OF MY KNOWLEDGE, THAT THE INFORMATION REPORTED HEREIN IS TRUE, CORRECT AND COMPLETE. Signature Date Printed/Typed Name Title Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 59 Texas Dept of Family and Protective Services Internal Control Structure Questionnaire (ICSQ) for POS Form 9007POS September 2002 Instructions for Submitting A current “up- to-date” Internal Control Structure Questionnaire is required to be submitted with each new proposal to contract with the Agency FPS. If you have never submitted a previous ICSQ, you will need to complete the attached ICSQ. However, if you have other contracts/proposals with FPS, you are only required to submit one ICSQ for those contracts that share or abide by same controls. Therefore, if you have submitted an ICSQ with a different proposal (within the past year), and same control structure applies to this contract, you may submit a ”copy” of that ICSQ as long as it is current and applicable to this contract, and covers all sections on this ICSQ. If not all sections are covered, you will need to complete the applicable sections on this ICSQ and submit this ICSQ along with the “copy” of the previously submitted ICSQ. No two-sided copies will be accepted. No pamphlets or books will be accepted. Responses must be typed or printed. Any response that requires an attachment should reference the attachment number in the response and the attachment must be clearly numbered. Instructions for Completing Every agency, organization, university, and/or other business entity should have internal controls in place. Internal controls basically ensure that assets (such as cash and equipment) are safeguarded, that expenditure transactions (such as purchases) are authorized, and that financial data are accurately recorded. Another way of saying this is that a system of internal controls assures that assets that belong to the business are received when tendered, are protected while in the custody of the business, and are used only for authorized business purposes. A system of internal controls is not designed primarily to detect errors but rather to reduce the opportunity for errors or dishonesty to occur. In an effective system of internal controls, no one person should carry out all phases of a business transaction from beginning to end. For example, if one person were permitted to order supplies, receive the supplies, write a check to pay for the supplies, and record the transaction in the accounting records, there would be no protection against either fraud or errors. Internal controls consist of the policies and procedures that a business develops and implements to minimize risk. To determine if a business has internal controls, numerous questions can be asked regarding the business’ processes/procedures for handling cash receipts, cash disbursements, physical inventory, and file maintenance, etc. In addition, the ICSQ has questions that are specific to state and federal regulations/guidelines. A system of internal controls frequently may be improved by physical safeguards (acting as compensatory controls). Computers help to improve the efficiency and accuracy of record keeping functions. Cash registers, safes, and pre-numbered business forms are very helpful in safeguarding cash and establishing responsibility for it. Any system of internal controls must be supervised with care if it is to function effectively. Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 60 The cost of a system of internal controls must be balanced against the benefit to be derived in preventing errors and losses. The ICSQ has been divided into several sections, covering the below purposes as follows: SECTION I: FINANCIAL POSITION (This section is self-explanatory.) SECTION II: INTERNAL CONTROLS This section mainly addresses Internal Controls as described below: II. A. GENERAL/ACCOUNTING CONTROLS The general section basically addresses file maintenance and the contractor’s responsibility to meet contract terms and/or state/federal regulations. Accounting controls are concerned with the safeguarding of assets (cash and fixed assets) and the reliability of financial records. The objective sought in the control of cash receipts is to assure that all cash that is receivable by the business is collected and recorded without loss. The system of controlling cash payments should be designed to ensure that no unauthorized payments are made. Control is accomplished by division of responsibility to achieve independent verification of cash transactions without duplication of effort. Number 3: An element of a good file maintenance process is a systematic filing approach for the numerous documents that flow through a business. A systematic filing approach decreases the risk of losing documents, having documents that pertain to the same issues placed in several locations, and not knowing what changes have occurred related to similar issues. Therefore, a business should have contract files that include the information enumerated in Number 3. Number 4: All costs that are reported and/or billed as FPS costs should be reconciled with the general ledger (the book or file that contains all or groups of the organization’s accounts). Number 5: The accounting system used must adequately identify the receipt and expenditures of funds separately for each contract and/or source of funds. Direct costs for each contract must be clearly identified by the accounting system (consider: How are travel expenses recorded when traveling for the FPS contract?). Separate general ledger account numbers for revenues and expenses incurred under the contract should be evident. For example: 400 - 699 Support and Revenue Accounts 401 FPS revenue - FPS Guardianship Services 402 FPS revenue - STAR contract 403 FPS revenue - FPS Parenting Training 700 - 999 Expenses 700 - 709 Salaries 700 Salaries - FPS Guardianship Services Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 61 701 702 810 - 819 811 812 813 Salaries - STAR contract Salaries - FPS Parenting Training Supplies Consumable Supplies - FPS Guardianship Services Consumable Supplies - FPS Parenting Training Consumable Supplies - Star Contract Number 7: Costs should be allocated in accordance with relative benefits or other equitable relationship. Number 8: Total expenditures for FPS contracts must be monitored against the total contract budget (Form 2030). For example there must be a system for monitoring the expenditures for salaries against the contract budget category for salaries. Numbers 11-17: These questions should only be answered if the accounting system is automated. Number 18: This is good business practice. Authorized individuals for departments should be required to approve purchases made on behalf of their department. Number 19: This helps to control disbursements of checks. Numbers 31: If the supporting documents are not maintained with each disbursement, the supporting documents should be numbered, clearly referenced, and filed for easy retrieval. Work papers are necessary to provide documentation during monitoring visits and/or audits. Numbers 32-33: These procedures are good business practices and aid in accurate record keeping, since it is easier to remember what happened last month rather than what happened months ago. Number 34: This is extremely important if an invoice is allocated to more than one funding source. Number 35: Contractors should know how to access or obtain copies of the Texas Administrative Code (TAC) and applicable Office of Management and Budget (OMB) Circulars. Number 38: This is a contract term. A fidelity bond is also known as dishonesty bonding under a commercial crime policy, employee crime insurance policy, or business services bonding. A copy of the proof of insurance may be requested for your contract file since this is a contract term. Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 62 “Appropriate positions” would include, at a minimum, employees who handle cash (including petty cash), employees with check-signing authority, employees authorized to transfer bank funds, and employees responsible for equipment inventory. Often, the policy will be a blanket policy, covering all employees Numbers 39-40: Generally the contract requires commercial general liability coverage with a $300,000 minimum for each occurrence limit and $600,000 aggregate minimum limit, see contract for specifics. This question may not be applicable to governmental entities, since most are self-insured. This is good business practice. If assets were purchased with FPS funds, the federal regulations require that adequate insurance coverage be maintained. Fire, flood and theft insurance should be of an amount to cover the value of the type of asset being insured (building, equipment, personal property). The historical values of the assets are shown in the general ledger assets accounts (and on a balance sheet). II. B. PERSONNEL Businesses should have written personnel policies available to all employees. The policies need to be consistently applied. These written personnel policies should include the business’ policies concerning benefits. Questions to be asked: Do all employees have the same fringe benefits? Do some employees have more benefits than others? Are the benefits consistent with the personnel policies? Number 44: OMB Circular A-122, Attachment B, Paragraph 7, subparagraph “m” (revised June 1, 1998) and OMB Circular A-87, Attachment B, Paragraph 11, subparagraph “h” (revised August 29, 1997) address documentation necessary to support salaries and wages. These circulars further state that the allocation of direct service delivery staff salaries between programs and/or contracts must be documented. (Travel Costs Paid with FPS Funds) Number 48: Supporting documentation would be receipts required for parking fees, hotels, taxis, and airfare. II. C. TRAVEL Number 49: Travel must be in conformance with the state travel requirements and rates for lodging, meals, and personal vehicle mileage. Limitations for out-of-state meals and hotels can be obtained by telephoning the Texas Comptroller’s Office in Austin at 512/475-0966.A free copy of the Comptroller’s Travel Allowance Guide (TAG) can be obtained by telephoning the Texas Comptroller’s Office in Austin at 512/475-0966 or on the Internet: http://window.state.tx.us/comptrol/san/fm.notices.date.html/fm02/fm02-09b.html Number 50: The approval must be in writing and maintained with the travel voucher/travel log. The budget narrative should also have included a reference to out-of-state travel costs. Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 63 II. D. EQUIPMENT Numbers 51-61: Equipment is defined in 45 Code of Federal Regulations (CFR) Part 74 and the Office of Federal Financial Management, Office of Management and Budget (OMB) Circulars. Equipment purchased through the contract is subject to an equitable claim by the state (FPS). The disposition of all equipment purchased with federal funds must be made according to appropriate regulations and departmental policies, as per OMB Circular A-110, Section 33 (G). No disposition should take place without prior notification to FPS contract management. Question #58 is a federal requirement that a physical inventory be taken at least once every two years for equipment acquired with federal funds. II. E. SUBCONTRACTORS Number 62: This section must be completed if use of subcontractors is indicated on the current Form 2046 (Certification regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion for Covered Contracts) on file. Number 64: These individuals should be qualified and or trained and hold an appropriate position that allows decision making at the level required as per the contractor’s purchasing policy. Number 66: Any subcontract for direct services must either state or include all the terms and conditions of the prime contract for subcontractors. Number 67: Contractor oversight should be sufficient to ensure that subcontractors consistently provide quality services by measuring performance against well-documented expectations. The subcontract monitoring procedures review process will check for sound monitoring practices and sound business practices. The monitoring function should focus on the outcomes of services provided with an appropriate emphasis on contract monitoring in proportion to the amount/extent of the contracted services. Procedures would adequately describe who is responsible for monitoring, how often monitoring would occur, the monitoring process to include follow-up that requires corrective action as a result of monitoring reviews, and clearly defined termination procedures. Information provided in #65.b., c., f., & g. should be included in these procedures. Good business practice would include an ongoing system for checking the background/credentials of potential and existing contractors and that funds are spent appropriately. Number 68: Procurement policies and procedures should reflect a system in which the best subcontractor is fairly and objectively selected. Procedures should clearly identify which method of contractor selection is utilized for the different types of procurements (thresholds for competitive bidding, negotiation with individual). (OMB Circular A-110, Sections 40-48.) Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 64 The contractor selection process would include established criteria to evaluate potential contractors, ranking method, and the consideration of past performance factors. FPS is committed to encouraging participation and increased opportunities for minority and women-owned businesses, including non-profit businesses that cannot be certified by the General Services Commission as a HUB. FPS requires contractors who have contracts with FPS of $100,000 or more to do the same. A good faith effort requires that contractors maintain documentation in purchase and contract files of their efforts to utilize HUBs. When HUB bidders are not solicited or selected, documentation should clearly state the reason. Contractors who have contracts with FPS of $100,000 or more are required to have a HUB Subcontracting Plan that documents either: a) That contractor does not plan to subcontract any components of the FPS contract, or b) That contractor does plan to subcontract and includes at minimum the contractor’s written policy/procedures for subcontracting and contractor’s methods for soliciting and selecting subcontractors. Number 69: This item addresses the contract term which requires that subcontracts for services delivered under the contract be approved by the Department. Services refer to all services required to be delivered under the contract. The completion of a Subcontractor Documentation Form is required for all subcontractors. II. F. RELATED-PARTY TRANSACTIONS Numbers 70-83: This section deals with doing business with related parties. A related party is a person or organization related to the contracted provider entity by blood/marriage, common ownership, or any association which permits either entity to exert power or influence (control), either directly or indirectly, over the other. Two or more individuals or organizations constitute related parties whenever they are affiliated or associated in a manner that entails some degree of legal control or practical influence of one over the other. This affiliation or association may be based on common ownership, past or present mutual interests in healthcare or other types of enterprises, or family ties. In determining whether a related party relationship exists with the contracted provider, the tests of common ownership and control are applied separately. Control exists where an individual or organization has power, directly or indirectly, significantly to influence or direct the actions or policies of an organization or institution. If the elements of common ownership or control are not present in both organizations, the organizations are deemed not to be related to each other. The existence of an immediate family relationship will create an irrefutable presumption of relatedness through control or attribution of ownership or equity interests where the significance tests are met. The following persons are considered immediate family: (1) husband and wife; (2) natural parent, child and sibling; (3) adopted child and adoptive parent; (4) stepparent, stepchild, stepsister, and stepbrother; (5) father-in-law, mother-in-law, brother-in-law, son-in-law, sister-in-law, and daughterin-law; (6) grandparent and grandchild; (7) uncles and aunts by blood or marriage; (8) nephew and nieces by blood or marriage; and (9) first cousins. Related party transactions include the purchase/lease of facilities, services, equipment, or supplies from the contracted provider’s central office or related organization(s). The allowable cost in a related-party transaction will be examined to determine their reasonableness, meaning that such Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 65 cost must not exceed the price of comparable services, facilities, equipment or supplies if they were to be purchased from a non-related vendor on the open market. Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 66 Texas Dept of Family and Protective Services Corporate Board of Directors Resolution , COUNTY OF Form 2031 May 2004 STATE OF On the day of , , at a meeting of the Board of Directors of , , a Corporation, held in the City of County, with a quorum of the Directors present, the following business was conducted: It was duly moved and seconded that the following resolution be adopted: BE IT RESOLVED that the Board of Directors of the above corporation do hereby authorize and his/her successors in office to negotiate, on terms and conditions that he/she may deem advisable, a contract or contracts with the Texas Department of Family and Protective Services, and to execute the contract or contracts on behalf of the Corporation, and further we do hereby give him/her the power and authority to do all things necessary to implement, maintain, amend, or renew the contract. The above resolution was passed by a majority of those present and voting in accordance with the Bylaws and Articles of Incorporation. I certify that the above and foregoing constitutes a true and correct copy of a part of the minutes of a meeting of the Board of Directors of held on the day of , . Secretary Subscribed and sworn before me, , on the day of , a Notary Public for the County of , . Notary Public County of Notary Public State of Notary Public Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 67 Texas Dept of Family and Protective Services Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion for Covered Contracts Form 2046 May 2004 Federal Regulations (45 CFR part 76) require the Texas Department of Family and Protective Services (DFPS) to determine whether each potential contractor has been debarred or suspended or proposed for debarment or suspension under 48 CFR part 9, are ineligible, as defined in 45 CFR §76.105(i) or has accepted a voluntary exclusion. Each covered contractor must also make the same determination for each of its covered subcontractors. Contractors and subcontractors are both referred to as lower tier participants in this Certification. Instructions for Certification By signing and submitting this proposal, the prospective lower tier participant is providing the certification set out below: 1. The certification in this clause is a material representation of fact upon which reliance was placed when this transaction was entered into. If it is later determined that the prospective lower tier participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment. 2. The prospective lower tier participant shall provide immediate written notice to the person to which this proposal is submitted if at any time the prospective lower tier participant learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances, whether the circumstances occur before the contract begins, during the term of the contract, or during the term of an extension of the contract. 3. The terms covered transaction, debarred, suspended, ineligible, lower tier covered transaction, participant, person, primary covered transaction, principal, proposal, and voluntarily excluded, as used in this clause, have the meaning set out in the Definitions and Coverage sections of federal rules implementing Executive Order 12549. You may contact the person to which this proposal is submitted for assistance in obtaining a copy of those regulations. 4. The prospective lower tier participant agrees by submitting this proposal that, should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4, debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the department or agency with which this transaction originated. Do you have or do you anticipate having subcontractors under this proposed contract? Yes No 5. The prospective lower tier participant further agrees by submitting this proposal that it will include this clause titled "Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion-Lower Tier Covered Transaction," without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions. 6. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that it is not proposed for debarment under 48 CFR part 9, subpart 9.4, debarred, suspended, ineligible, or voluntarily excluded from covered transactions, unless it knows that the certification is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. Each participant may, but is not required to, check the List of Parties Excluded from Federal Procurement and Nonprocurement Programs. 7. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings. Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 68 Texas Dept of Family and Protective Services Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion for Covered Contracts Form 2046 May 2004 8. Except for transactions authorized under paragraph 5 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4, suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment. Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion--Lower Tier Covered Transactions Indicate in the appropriate box which statement applies: The prospective lower tier participant certifies, by submission of this proposal, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency. OR Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective participant has attached an explanation to this certification. Name of Potential Contractor Vendor ID No. or Social Security No. DFPS Contract No. (if applicable) Signature of Authorized Representative Date Printed/Typed Name of Authorized Representative Title Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 69 Texas Dept of Family and Protective Services Certification Regarding Federal Lobbying (Certification for Contracts, Grants, Loans, and Cooperative Agreements) Form 2047e May 2004 PREAMBLE Federal legislation, Section 319 of Public Law 101-121 generally prohibits entities from using federally appropriated funds to lobby the executive or legislative branches of the federal government. Section 319 specifically requires disclosure of certain lobbying activities. A federal government-wide rule, "New Restrictions on Lobbying," published in the Federal Register, February 26,1990, requires certification and disclosure in specific instances and defines terms: Covered Awards and Subawards - Contracts, grants, and cooperative agreements over the $100,000 threshold need (1) certifications, and (2) disclosures, if required. (See certification term number 2 concerning disclosure.) Lobbying - To lobby means "to influence or attempt to influence an officer or employee of any agency (federal), a member of Congress, an officer or employee of Congress, or an employee of a member of Congress in connection with any of the following covered federal actions:  the awarding of any federal contract,  the making of any federal grant,  the making of any federal loan,  the entering into of any cooperative agreement, and  the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan or cooperative agreement." Limited Use of Appropriated Funds Not Prohibited - The prohibition on using appropriated funds does not apply to activities by one's own employees with respect to:  liaison activities with federal agencies and Congress not directly related to a covered federal action;  providing any information specifically requested by a federal agency or Congress;  discussion and/or demonstration of products or services if not related to a specific solicitation for a covered action; or  professional and technical services in preparing, submitting or negotiating any bid, proposal or application for a federal contract, grant loan or cooperative agreement or for meeting legal requirements conditional to receipt of any federal contract, grant, loan or cooperative agreement. (The prohibition also does not apply to such services provided by nonemployees for the same purposes.) Professional and Technical Services - Professional and technical services shall be advice and analysis directly applying any professional or technical expertise. Note that the professional and technical services exemption is specifically limited to the merits of the matter. Other Allowable Activities - The prohibition on use of federally appropriated funds does not apply to influencing activities not in connection with a specific covered federal action. These activities include those related to legislation and regulations for a program versus a specific covered federal action. Funds Other Than Federal Appropriations - There is no federal restriction on the use of nonfederal funds to lobby the federal government for contracts, grants, and cooperative agreements. Applicability of Other State and Federal Requirements - Neither the government-wide rule nor the law affect either (1) the applicability of cost principles in OMB circulars A-87 and A-122, or (2) riders to the Texas State Appropriations Acts which disallow use of state funds for lobbying. TERMS OF CERTIFICATION This certification applies only to the instant federal action for which the certification is being obtained and is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 70 Texas Dept of Family and Protective Services Certification Regarding Federal Lobbying (Certification for Contracts, Grants, Loans, and Cooperative Agreements) Form 2047e May 2004 The undersigned certifies, to the best of his or her knowledge and belief, that: 1. No federally appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress in connection with the awarding of any federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, or the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan, or cooperative agreement. If any funds other than federally appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress in connection with this federally funded contract, subcontract, subgrant, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions. (If needed, contact your Texas Department. of Family and Protective Services procurement officer or contract manager to obtain a copy of Standard Form-LLL.) The undersigned shall require that the language of this certification be included in the award documents for all covered subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all covered subrecipients shall certify and disclose accordingly. Yes No 2. 3. Do you have or do you anticipate having covered subawards under this transaction? Name of Contractor/Potential Contractor Vendor ID No. or Social Security No. DFPS Contract No. Signature- Authorized Representative Date Name of Authorized Representative Title Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 71 Texas Dept of Family and Protective Services Nongovernmental Contractor Certification Form 4732e May 2004 The Texas Department of Family and Protective Services (DFPS) has adopted rules pertaining to contracting with organizations in which a former board member or employee (whose last day of duty was within the past two years) has any ownership or control, or who is an employee or consultant of such organization. Also, Human Resources Code §22.0033 prohibits for one year after employment former DFPS employees in pay grades equivalent to or above pay grade 17, Step 1, from helping (for pay) another entity obtain a contract with DFPS in an area for which the former employee was directly concerned or had administrative responsibility. Additionally, DFPS has adopted standards for contracting with contractors associated with current or former employees and board members, and their relatives. This form is necessary to help the Department determine compliance with those rules. All potential non-governmental contractors for any type of contract must complete this certification. The contract, if awarded, may be terminated for cause if: (1) The contractor knowingly provides incorrect information in its certification; or (2) The contractor uses a subterfuge, such as a subcontract arrangement, to avoid the application of state laws or DFPS rules. Does the potential contractor have as an officer, director, employee, consultant, or owner (in whole or in part): 1. 2. A person who is currently a DFPS employee or DFPS board member? A person who was a former DFPS employee or board member whose last day of duty with DFPS was within the past two years? A person who is related (see Relationship key below) to a current DFPS employee or DFPS board member? A person who is related (see Relationship key below) to a former DFPS employee or DFPS board member whose last day of service to DFPS was within the past two years? Wife Husband Father Mother Brother Sister Son Daughter Stepdaughter Stepson Mother-in-law Father-in-law Yes No Yes No 3. Yes No 4. Yes Spouse's Sister Spouse's Brother No RELATIONSHIP KEY IF YOU ANSWERED "YES" TO ANY OF THE ABOVE QUESTIONS, YOU MUST COMPLETE AND ATTACH FORM 4732ae. CERTIFICATION I certify that the information above is complete, true and correct to the best of my knowledge. I understand that lack of full, true and complete disclosure may be grounds for withholding payment for delivered services and may cause contract termination. Name of Potential Non-governmental Contractor Contract No. Amendment No. Social Security No. or VIN Print or Type Name Signature-Authorized Representative Date Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 72 Texas Dept of Family and Protective Services Nongovernmental Contractor Certification (Part II) Form 4732ae May 2004 As a condition for receiving a contract or having a contract renewed, potential contractors who answered "yes" to any of the questions on Form 4732e must complete the questions on this form (Form 4732ae). The questions must be fully answered and the certification on Page 2 must be completed and signed. The answers are used to determine compliance with Texas Department of Family and Protective Services rules found in the Texas Adm. Code, Title 40, Chapter 73, §§79.1801-79.1807. 1. Regarding Past And Current DFPS Employees And Board Members Did you answer "yes" to question 1 or 2 on Form 4732e? Yes No If "no," skip to question 2. If "yes," complete the following information for those persons. If they are FORMER DFPS employees, indicate whether association with the potential contractor resulted in a 25% or more increase in overall annual benefits (including salary) over what was received when the person was with DFPS. Person Associated with Potential Contractor Program/Support Area at DFPS Last/Current Position at DFPS Beginning Date Beginning Date Ending Date Current Position with Potential Contractor 25% or More increase in Compensation Yes Person Associated with Potential Contractor Program/Support Area at DFPS Last/Current Position at DFPS Beginning Date Beginning Date No Ending Date Current Position with Potential Contractor 25% or More increase in Compensation Yes Person Associated with Potential Contractor Program/Support Area at DFPS Last/Current Position at DFPS Beginning Date Beginning Date No Ending Date Current Position with Potential Contractor 25% or More increase in Compensation Yes 2. Regarding Those Associated with Potential Contractors and the Associates' Relatives No Did you answer "yes" to question 3 or 4 on Form 4732e? .............................................................................................................. If "no," skip to question 3. If "yes," complete the following information for those persons and their relatives. Name of Person Associated with Potential Contractor Name of Current/Former DFPS Employee/Board Member Last/Current Position Held at DFPS (use job title) Current Position with Potential Contractor Relationship to Person Associated with Potential Contractor Program/Support Area at DFPS Beginning Date Yes No Beginning Date Ending Date Name of Person Associated with Potential Contractor Name of Current/Former DFPS Employee/Board Member Last/Current Position Held at DFPS (use job title) Current Position with Potential Contractor Relationship to Person Associated with Potential Contractor Program/Support Area at DFPS Beginning Date Beginning Date Ending Date Name of Person Associated with Potential Contractor Name of Current/Former DFPS Employee/Board Member Last/Current Position Held at DFPS (use job title) Current Position with Potential Contractor Relationship to Person Associated with Potential Contractor Program/Support Area at DFPS Beginning Date Beginning Date Ending Date Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 73 Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 74 Texas Dept of Family and Protective Services Nongovernmental Contractor Certification (Part II) Form 4732ae May 2004 3. Prohibitions Against Contracts with Certain Former Employees A. Has the potential contractor and/or any of his employees been employed by DFPS within the last 12 months? If "NO," skip to number 4. .............................................................................................................................................................. Is a former employee, or an organization controlled (in part or whole) by a former employee, applying for this contract? ............ Has (or will) the former employee(s) be paid to aid in the development of or the attempt to obtain the proposed contract? ......... Does the proposed contract relate to a program or service in which the potential contractor/employee(s) (while with DFPS) was directly concerned or had administrative responsibility? .......................................................................................................... If the answer is "Yes" to "B" and "D," or "C" and "D," provide the former DFPS employee's name and indicate whether they earned an annualized gross salary of $30,588 or more at the time he left employment with DFPS. ...................................... Yes Yes Yes No No No B. C. D. Yes No E. Yes No Name $30,588 or more? Yes Yes Yes No No No 4. Financial Interest - Provide the name and other requested information about any person who is owner (in part or whole), officer, director, employee, or consultant employed or associated with your organization and who A. B. C. D. E. was a member of the DFPS Board and who left within the past two years; is now a member of the DFPS Board; was an employee of DFPS and who left within the past two years; is now an employee of DFPS; or is related in a manner specified in Question 3 or 4 of Form 4732e, to the persons in items A, B, C, or D immediately above. Owns 10% or more? Yes Yes Yes No No No $2,500 or more investment? Yes Yes Yes No No No Name CERTIFICATION I certify that the information above is complete, true and correct to the best of my knowledge. I understand that lack of full, true and complete disclosure may be grounds for withholding payment for delivered services and may cause contract termination. Name of Potential Non-governmental Contractor Contract No. Amendment No. Description of Contracted Service/Item Social Security No. or VIN Print or Type Name Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 75 Signature-Authorized Representative Date Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 76 Texas Dept of Family and Protective Services Child Support Certification Form 9003 May 2004 §231.006. Ineligibility to Receive State Grants or Loans or Receive Payment on State Contracts Texas Family Code, Title 5. The Parent-Child Relationship Subtitle D. Administrative Services Chapter 231. Title IV-D Services Subchapter A. Administration of Title IV-D Program (a) A child support obligor who is more than 30 days delinquent in paying child support and a business entity in which the obligor is a sole proprietor, partner, shareholder, or owner with an ownership interest of at least 25 percent is not eligible to: (1) receive payments from state funds under a contract to provide property, materials, or services; or (2) receive a state-funded grant or loan. (b) A child support obligor or business entity ineligible to receive payments under Subsection (a) remains ineligible until: (1) all arrearages have been paid; or (2) the obligor is in compliance with a written repayment agreement or court order as to any existing delinquency. (c) A bid or an application for a contract, grant, or loan paid from state funds must include the name and social security number of the individual or sole proprietor and each partner, shareholder, or owner with an ownership interest of at least 25 percent of the business entity submitting the bid or application. (e) If a state agency determines that an individual or business entity holding a state contract is ineligible to receive payment under Subsection (a), the contract may be terminated. (f) If the certificate required under Subsection (d) is shown to be false, the vendor is liable to the state for attorney’s fees, the costs necessary to complete the contract, including the cost of advertising and awarding a second contract, and any other damages provided by law or contract. Under Section 231.006, Family Code, the vendor or applicant certifies that the individual or business entity named in this contract, bid, or application is not ineligible to receive the specified grant, loan, or payment and acknowledges that this contract may be terminated and payment may be withheld if this certification is inaccurate. Signature of individual with 25% or more interest in the business entity Printed Name: Social Security Number Date: Name of Business Entity: Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 77 Texas Dept of Family and Protective Services Instructions for Client Services HUB Subcontracting Plan: Forms 9151ASD and 9151SSD [Unit Rate or Fixed Price or Fee-for-Service] Form 9151INS May 2004 These forms should be requested of private contractors entering client service contracts for $100,000 or more except cost reimbursement contracts. Contractors must complete the 9152 forms for cost reimbursement contracts or the 9150 forms for any type of Business Service contracts. Although DFPS must request the applicant or contractor to complete the 9151 forms, it is not mandatory that the applicant or contractor completes them. The 9151 forms are the proper forms to use for Residential Child Care and Adoption contracts. 9151ASD Question 1: Enter the full legal entity name. This may include the d.b.a. (doing business as). The full legal name should be consistent in all references in this document and all forms returned by the contractor, as well as in the certificate printed from the Comptroller. The formal name as currently confirmed by the Secretary of State may be used instead of the name as used by the Comptroller if the Secretary of State's file number is the same. Question 2: Enter the 11 or 14-digit Vendor Identification Number assigned by the State of Texas Comptroller or the 9digit Federal Tax Identification Number issued by the Internal Revenue Service. Question 3: To answer yes to this question, the organization must have the actual certification document from TBPC or its predecessor, GSC. Print the certification number. If you are able to answer yes, skip questions 4-7 and continue with Question 8. Question 4: If you are not certified as a HUB by TBPC/GSC, but have been certified by another certifying agency, answer “YES”, include the name of the certifying agency, and attach a copy of the certification. Continue answering all questions whether you answer yes or no. Answer “No”, if you have never been certified by any agency. Question 5: If you have not been approved for non-profit status by the State of Texas or by the Internal Revenue Service, answer yes. If yes, indicate which group best describes the individuals who own at least 51% of the assets and interest and/or classes of stock and equitable securities. These individuals must demonstrate an active participation in the control, operation and management of firm’s daily business affairs. Definitions are available at the TBPC web site – http://www.tbpc.state.tx.us. Question 6: Indicate whether your primary place of business is in Texas. Question 7: Indicate whether or not you have maintained gross receipts or total employment levels four consecutive years in excess of any of the listed categories of the U.S. Small Business Administration’s size standards. Question 8: Check the box if you will not subcontract any portion of the contract/agreement. All contractors, including certified HUBS, should complete Form 9151SSD if any contract activities will be subcontracted. This form must be signed by the person authorized by the contractor to sign contracts. 9151SSD Multiple copies may be needed if a contractor will be using several subcontractors. Please do not list subcontractors with an estimated dollar value lower than $1,000. 1. Enter the full legal entity name. This may include the d.b.a. (doing business as). The full legal name should be consistent in all references in this document and all forms returned by the contractor, as well as in the certificate printed from the Comptroller. The formal name as currently confirmed by the Secretary of State may be used instead of the name as used by the Comptroller if the Secretary of State's file number is the same. Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 78 2. The DFPS staff should have filled in the Contract Number or Procurement Number. If not, please fill in, or if you do not know it, leave it blank. Enter the name of each subcontractor you are using or propose to use during the contract period. Enter the address of each subcontractor. Enter the estimated dollar value of each proposed subcontract. Describe the proposed subcontracted goods or services. If a proposed subcontractor is certified as a HUB, by any agency, enter the certification number and the name of the certifying agency. If a proposed subcontractor is HUB qualified, but not certified, enter the qualifying ethnicity and/or gender of the subcontractor. 3. 4. 5. 6. 7. 8. Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 79 Texas Dept of Family and Protective Services Client Services HUB Subcontracting Plan Applicant Status Determination [Unit Rate or Fixed Price or Fee-for-Service] Form 9151ASD May 2004 PREAMBLE: DFPS and other Health and Human Services agencies are committed to promoting full and equal business opportunities for all businesses in state contracting. To better promote these opportunities, it is imperative that we collect information on prime contractors and their subcontractors to determine if an entity meets the Texas Buildings and Procurement Commission (TBPC) Historically Underutilized Business (HUB) certification criteria. PURPOSE: The purpose of the Applicant Status Determination form 9151ASD and the Subcontractor Status Determination form 9151SSD is to collect HUB-related information about a prime contractor and its subcontractors. PROCEDURE: Please complete this form with information about the prime contractor. Complete Form 9151SSD (additional copies may be attached if necessary) with information about subcontractors. Return the signed and completed forms to the procurement officer at the Texas Department of Family and Protective Services. If this form is requested during a contract, return it to the contract manager. After DFPS reviews the information, a representative may contact you to share additional information about HUB certification and reporting. Information on the State of Texas HUB program can be found on the TBPC website at http://www.tbpc.state.tx.us/ or by contacting the DFPS HUB Coordinator at 512/832-2046. 1. Print Legal Name of Contractor: 2. Print the 11 or 14-digit Vendor Identification Number assigned by the State of Texas Comptroller or the 9-digit Federal Tax ID: 3. Is Contractor a TBPC certified HUB? (See HUB definition on form Yes No 9151SSD.) If yes, please give your TBPC Certification No. and continue with Question 8. 4. Is Contractor certified as a minority/women-owned business from an agency other than the TBPC? If yes, attach a copy and give name of certifying agency. Yes No 5. Is the owner or company a for-profit entity? Yes No If yes, please indicate which group best describes the individuals who own at least 51% of the assets and interest and/or classes of stock and equitable securities. These individuals must demonstrate an active participation in the control, operation and management of firm’s daily business affairs. Male Female Group Asian Pacific American (AS) Black Americans (BL) Hispanic Americans (HI) Native Americans (NA) American Women who is not in the categories above (WO) None of the above 6. Is your primary place of business in Texas? Yes No Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 80 7. Has the Contractor maintained gross receipts or total employment levels four consecutive years in excess of any of the following? Yes No  Financial and Accounting - $17,000,000  Wholesale Commodities - 100 Full Time Employees  Medical and Other Services - $5,000,000  Manufactured Commodities - 500 Full Time Employees 8. If Prime Contractor will NOT subcontract any portion of the contract/agreement, please check this box. Complete Form 9151SSD if any contract/agreement activities will be subcontracted. To the best of my knowledge, I certify the above information to be true and complete. Signature of Contractor's Authorized Representative Date Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 81 Texas Dept of Family and Protective Services Client Services HUB Subcontracting Plan Subcontractor Status Determination [Cost Reimbursement] Form 9152SSD May 2004 Applicant or Contractor’s Name: DFPS Contract or Procurement Number: Prime contactor should contact Subcontractor to obtain information as required to complete this form. Include each current or proposed Subcontractor. If certified as a Minority/ Women- If HUB* Qualified, Estimated Subcontractor Description of Subcontracted Owned Business, but not Certified Address Dollar Value of Name Goods and/or Services enter certification enter Qualifying Subcontract number and Ethnicity/Gender certifying entity *A Historically Underutilized Business (HUB) is defined as a business that is formed for the purpose of making a profit and is otherwise a legally recognized business organization under the laws of the State of Texas. At least 51% of the assets and interest and/or classes of stock and equitable securities must be owned by one or more persons who are United States citizens born or naturalized. The following are recognized by the State of Texas as having been economically disadvantaged because of their identification as members of the qualifying groups - Asian Pacific Americans (AS), Black Americans (BL), Hispanic Americans (HI), Native Americans (NA), and American Women (WO). These individuals must demonstrate active participation in the control, operation and management of the daily business affairs of the company that is proportionate to their ownership interest. HUB businesses must have a permanent business office located in Texas where the majority HUB owner(s) makes the decisions, controls the daily operations of the organization, and participates in the business. Owners must be residents of the State of Texas and meet all other certification and compliance requirements. Out-of-state businesses are ineligible for state certification. Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 82 Texas Department of Family and Protective Services CRIMINAL HISTORY STATEMENT CRIMINAL OFFENSES FROM THE TEXAS PENAL CODE: Title 5. Offenses Against the Person Murder Capital murder Voluntary manslaughter Involuntary manslaughter Criminally negligent homicide False imprisonment Kidnapping Aggravated kidnapping Aggravated rape Sexual abuse Aggravated sexual abuse Homosexual conduct Public lewdness Indecent exposure Rape of a child Sexual abuse of a child Indecency with a child Assault Aggravated assault Deadly assault on a peace officer Injury to a child Reckless conduct Terroristic threat Aiding suicide Tampering with consumer products Title 6. Offenses Against the Family Bigamy Incest Interference with child custody Enticing a child Criminal nonsupport Sale or purchase of a child Solicitation of a child Harboring a runaway child Violation of a court order Title 43. Public Indecency Prostitution Promotion of prostitution Aggravated promotion of prostitution Compelling prostitution Obscene display or distribution Obscenity Sale, distribution, or display of harmful material to a minor Sexual performance by a child I acknowledge that I have been informed of the following prohibition regarding agencies or individuals with a contractual agreement with the Texas Department of Family and Protective Services (TDFPS) for the provision of services to children between the ages of 0 to 19, with whom TDFPS has an open case record and has referred for services: A. Prohibition from serving in any capacity as an employee or volunteer for any person convicted within the previous 10 years of: 1. 2. 3. Any felony or misdemeanor classified as an offense against person or family; Any felony or misdemeanor involving public indecency; Any felony violation of any statute intended to control the possession or distribution of any substance included as a controlled substance in the Texas Controlled Substances Act. B. Removal from contact with children or termination of the contract of any person for any of the following reasons: Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 83 Texas Dept of Family and Protective Services 1. Criminal History Statement Page 2 An indictment alleging commission of a felony classified as an offense against the person or family, or of public indecency, or of a felony violation of any statute intended to control the possession or distribution of any substance included as a controlled substance in the Texas Controlled Substances Act; An indictment alleging commission of a misdemeanor classified as an offense against the person or family or of public indecency; An official criminal complaint accepted by a district or county attorney alleging commission of a misdemeanor classified as an offense against the person or family or of public indecency. 2. 3. I acknowledge that I have examined the above list of violations within the prohibited class and that I am providing the following information related thereto: 1. I have have not been convicted within 10 years preceding this date of a felony or a misdemeanor within the prohibited class or any felony violation of any statute intended to control the possession or distribution of any substance included as a controlled substance in the Texas Controlled Substances Act. I am am not currently under indictment or charged in an official criminal complaint accepted by a district or county attorney with a felony or misdemeanor within the prohibited class. 2. I have read this form in its entirety, including the list on page 1, and understand that the information may be verified by the Texas Department of Family and Protective Services and that the inclusion of any false information or the omission of any requested information is cause for my immediate debarment from providing services to the Department's clients. Signature Date Please provide the following information. Our Department will use this information to conduct a Criminal Background Check. Full Name (please print) SSN DOB Ethnicity Please use the spaces below to list any other names (aliases) you have used, such as maiden name, previous married names, etc. Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 84 Texas Dept of Family and Protective Services REQUEST FOR CHILD ABUSE/NEGLECT CENTRAL REGISTRY CHECK Form 2970 July 1999 The Texas Department of Family and Protective Services (FPS) operates a Central Registry that identifies persons whom FPS has found to have abused or neglected children. FPS strives to provide the results of the Central Registry check within 30 days. A person may request a Central Registry check on him or herself by completing, having notarized and submitting this request form to: Procurement Officer TDFPS – Contracts REQUIRED IDENTIFYING INFORMATION ON REQUESTER - The requester must provide all of this information in order for a check to be made: First Name Middle Name Last Name Other names or spellings used (married, maiden, alias, etc.) - First, Middle, Last (continue on back as needed) Residence Street Address Residence Telephone No. (A/C) Date of Birth City County State Zip Code Gender : Female SSN Male - Am Indian/AK Native (Hispanic) Am Indian/AK Native (non-Hispanic) Asian/Oriental (Hispanic) Asian/Oriental (non-Hispanic) Black (Hispanic) Black (non-Hispanic) Black-White (Hispanic) Black-White (non-Hispanic) Other (Hispanic) Other (non-Hispanic) White (Hispanic) White (non-Hispanic) Nat Hawaii/Pac is (Hispanic) Nat Hawaii/Pac is (non-Hispanic) Unable to Determine (or, none of the above) List other places you have resided (for a minimum of the past 5 years - continue on back as needed) SEND RESULTS OF CENTRAL REGISTRY CHECK TO: Requester, OR Designee Name of Designee: Procurement Officer TDFPS Mailing Address of Designee (City, State, Zip): 516-B Air Park RD Midland, TX 79705 RESULTS OF CENTRAL REGISTRY CHECK: FPS returns the results of the Central Registry check to the person or entity and mailing address indicated to the left. The requester is entitled to have the results provided to him or to designate another person or entity to receive it. NOTICE - NOTICE - NOTICE: The requester may not have exhausted all opportunities to contest findings in the Central Registry. Therefore, a requester who designates another person/entity to receive the results of the check is hereby provided notice and cautioned that if he or she disagrees with any such findings, that he or she may have the right to challenge any such findings, and that he or she is authorizing FPS to release any such findings to a third party prior to or during any challenge to the accuracy of those findings. Signature of Requester _______________________________________________ Date of Request _____________________ SUBSCRIBED AND SWORN TO before me this _____ day of _______________________________, ________. ___________________________________________ Notary Public [Notary stamp or seal] Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 85 Texas Dept of Family and Protective Services REQUEST FOR CHILD ABUSE/NEGLECT CENTRAL REGISTRY CHECK Form 2970 July 1999 FORMS INSTRUCTIONS: Purpose - to provide a form that an individual can use to request a child abuse and neglect records check from the FPS Central Registry of Child Abuse and Neglect. When to Use - FPS staff can partially complete and generate Form 2970 in order to give it to the requester for completion when a request for a central registry check is received verbally or when a written request not made on Form 2970 does not contain all the information required on Form 2970. A requester does not have to use Form 2970 to make this request but all the required information must be provided and the request must be notarized. How to Complete - Form 2970 can be accessed from the Smiley face icon, under the APS/CPS Shared Forms menu. Prior to printing the form, staff must enter an address in the first paragraph on the form to indicate where the requester is to send the completed form. Staff may obtain this address from the Regional Director in the region. Staff then print the form and provide it to the requester so that he can complete and submit it. Responding to Form 2970 When It Is Submitted - Staff designated by the Regional Director review the submitted form for completeness. If not complete and notarized, staff return the form to the requester for completing. If the form is complete and notarized, staff conduct a person search. If the person is found on CAPS, staff generate, complete as appropriate and print the Central Registry Response from CAPS. If the person is not found on CAPS, staff complete and print Form 2972, Child Abuse and Neglect Central Registry Check from the Smiley face icon (under the APS/CPS Shared Forms menu). Staff send the printed form to the requester or his designee. Retention - Form 2970 and a copy of the response are to be retained three years in administrative files, then destroyed in a manner consistent with observing the confidentiality of case and person information obtained from the central registry checks from CAPS. DETAILED INSTRUCTIONS: Enter the Name and Address of the Person Designated by the Regional Director to Receive Form 2970 - FPS staff enter the name and address of the person designated by the Regional Director to receive Form 2970. Required Identifying Information on Requester: First, middle, last name - The requester enters his legal name. Note: if the requester does not have a middle name, leave the ‘Middle Name’ field blank. Other Names or Spellings Used - First, Middle, Last - The requester enters his married name(s), maiden name, alias(es), name(s) he uses every day, etc., if different from his legal name. Residence street address, city, county, state, zip code - The requester enters this information on his current primary residence. Telephone number (A/C) - The requester enters his primary telephone number, including the area code. If none, leave blank. Date of Birth - The requester enters his birth date. Gender - The requester checks the box that represents the appropriate gender. SSN - The requester enters his social security number. Race/Ethnicity - The requester checks the box that represents his race and ethnicity. List other places you have resided (for a minimum of the past 5 years) - The requester enters the names of all the cities Texas where he has resided for at least the past 5 years, other than the current primary residence which has been given above. If none, leave blank. Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 86 Texas Dept of Family and Protective Services REQUEST FOR CHILD ABUSE/NEGLECT CENTRAL REGISTRY CHECK Form 2970 July 1999 Send Results of Central Registry Check to: Requester OR Designee - Name of Designee and Agency Designee Represents - At Mailing Address - The requester checks the appropriate box to indicate whether he wants the results of the central registry check sent directly to him or to a designee. If to a designee, the requester enters the name of the designee, the agency the designee represents and the mailing address to which the results of the central registry check are to be sent. Signature of Requester - The requester signs the form before a notary public. Date of Request - The requester enters the date he signed the form. Subscribed and Sworn to Before Me this __ _ day of __ provides the information and signs and stamps/seals the form. _ - Notary Public - Notary stamp or seal - The notary Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 87 Comptroller of Public Accounts FORM 74-158 (Rev. 10-98/7) For Comptroller’s use only VENDOR DIRECT DEPOSIT AUTHORIZATION INSTRUCTIONS • Use only BLUE or BLACK ink. • Alterations must be initialed. • Financial Institution must complete Section 4. • Section 7 must be completed by the paying state agency. • Check all appropriate box(es). For further Instructions, see the next page. New setup Cancellation Interagency Transfer (Sections 2, 3, & 4) (Sections 2 & 3) (Sections 2 & 3) Change financial institution Change account number Change account type (Sections 2, 3, & 4) (Sections 2, 3, & 4) (Sections 2, 3, & 4) Adoptive/Foster parents must enter the SSN and name of the spouse currently receiving payment. PAYEE IDENTIFICATION 1. Soc. Sec. No. (SSN) or Fed. Employer’s ID (FEI) 1.A. Facility/Provider/Contract/Vendor/Lease No. 3. Name 2. Mail Code (if not known, will be completed by Paying State Agency) 4. Business or daytime phone number ( 5. Mailing address 6. City ) 7. State 8. ZIP Code AUTHORIZATION FOR SETUP, CHANGES OR CANCELLATION 9. Pursuant to Section 403.016, Texas Government Code, I authorize the Comptroller of Public Accounts to deposit by electronic transfer payments owed to me by the State of Texas and, if necessary, debit entries and adjustments for any amounts deposited electronically in error. The Comptroller shall deposit the payments in the financial institution and account designated below. I recognize that, if I fail to provide complete and accurate information on this authorization form, the processing of the form may be delayed or that my payments may be erroneously transferred electronically. I consent to and agree to comply with the National Automated Clearing House Association Rules and Regulations and the Comptroller’s rules about electronic transfers as they exist on the date of my signature on this form or as subsequently adopted, amended or repealed. 10. Authorized signature 11. Printed name 12. Date FINANCIAL INSTITUTION (Must be completed by financial institution representative.) 13. Financial institution name 16. Routing transit number -18. Type of account Checking Savings 22. Phone number 23. Date 14. City 17. Customer account number Dashes required? -19. Financial institution representative name (Please print) 20. Title YES 15. State 21. Representative signature (Optional) ( FPS Form 4108x / 1098 ORIGINAL - Submit to FPS ) COPY - Retain for your records. Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 88 FOR INTERNAL USE (Optional) 24. State agency representative 25. Mail Code 26. Check this box if state agency representative to be notified. CANCELLATION BY AGENCY 27. Reason 28. Date PAYING STATE AGENCY (Fiscal Use Only) 29. Signature 31. Agency name 30. Printed name 32. Agency number 34. Phone number 35. Date 33. Comments ( FPS Form 4108x / 1098 ORIGINAL - Submit to FPS ) COPY - Retain for your records. Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 89 INSTRUCTIONS FOR VENDOR DIRECT DEPOSIT AUTHORIZATION SECTION 1: Check the appropriate box(es)  NEW SETUP - If payee is not currently on direct deposit with this agency. a. Complete Sections 2, 3 & 4. b. Financial Institution representative must complete Section 4.  CANCELLATION - If payee wishes to stop direct deposit with this agency. a. Payee completes Sections 2 & 3.  INTERAGENCY TRANSFER - For FPS use only.  CHANGE FINANCIAL INSTITUTION a. Payee completes Sections 2 & 3. b. The new financial institution representative completes Section 4.  CHANGE ACCOUNT NUMBER a. Payee completes Sections 2 & 3. b. Financial Institution representative completes Section 4.  CHANGE ACCOUNT TYPE a. Payee completes Sections 2 & 3 b. Financial Institution representative completes Section 4. Form 4108x P SECTION 2: PAYEE IDENTIFICATION Item 1 Leave the shaded boxes blank if you do not have your 11-digit Comptroller Texas Identification number. The paying state agency will provide the information to be entered in the shaded boxes. Enter your 9-digit Social Security number or your Federal Employer’s Identification (FEI) number. The number entered in this section should be the same number that is currently in use for processing your claims. Item 2 If your 3-digit mail code is not known, it will be assigned by the paying state agency. SECTION 3: AUTHORIZATION FOR SETUP, CHANGES OR CANCELLATION Items 10, 11 & 12 The individual authorizing must sign, print their name and date the form. NOTE: No alterations to this section will be allowed. SECTION 4: FINANCIAL INSTITUTION Section 4 must be completed by a financial institution representative Item 19 The financial institution representative’s name must be provided in Section 4. NOTE: Alterations to routing and/or account number must be initialed by the financial institution representative or the payee. SECTION 5: FOR INTERNAL USE The state agency contract manager or field staff may complete this section if they wish to be notified that this form has been processed by the Accounting Division. SECTION 6: CANCELLATION BY AGENCY Section 6 & 7 must be completed by the paying state agency. SECTION 7: PAYING STATE AGENCY Section 7 must be completed by the paying state agency before the form can be processed. Submit the Original Copy to: Accounting Division (E-672) Vendor Direct Deposit Texas Department of Family and Protective Services PO BOX 149030 AUSTIN, TX 78714-9030 Retain the Payee Copy for your records. Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 90 Form 4109X Page 90 Doc. Type Doc. No. I S AS U p d a t e Only T h i s a p p l i c a ti o n m u s t b e s u b m i t t e d b y e v e r y p e r s o n ( s o l e o w n e r , i n d i v i d u a l r e c i p i e n t , p a r t n e r s h i p , corporati on, or other organi zati on) w ho i ntends to bill the Texas Department of Fami l y and Protecti ve Servi ces for goods, servi ces provi ded, refunds, pu bli c assi stance, e tc. Y o u r T e x a s I d e n ti f i c a t i o n N o . ( T I N ) w i l l b e r e q u i r e d o n a l l v o u c h e r s s u b m i t t e d b y a n y s t a t e a g e n c y . Y o u r use of thi s TIN on all billings w ill reduce the time requi red to process your billings to the Sta te of Texas. F o r a s s i s t a n c e i n c o m p l e t i n g t h i s a p p l i ca t i o n , c a l l t h e P R S Ac c o u n t i n g D i v i s i o n a t ( 5 1 2 ) 4 3 8 - 2 8 8 4 .     P l e a s e D O N O T w r i t e i n s h a d e d b o x e s ( t h e s e a r e a s a r e f o r Ac c o u n t i n g D i v i s i o n u s e ) . P l e a s e D O N O T u s e d a s h e s w h e n e n t e r i n g S o c i a l S e c u r i t y , F e d e r a l E m p l o y e r ’ s I d e n ti f i c a t i o n ( F E I ) , o r Comptroll er’s assi gned numbers. D i s cl o s u r e o f y o u r S o c i a l S e c u r i t y N o . i s a u t h o r i z e d u n d e r t h e l a w ( O p . T e x . A t t ’ y . G e n . N o . H - 1 2 2 5 [ 1 9 7 8 ] ). Pl ease TYPE or PRINT all entri es. Mail Code N e w Ac c o u n t ( i n i t i a l s e t u p ) Yes (M ail 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. Indi cate type of number you are provi ding to be used for your TI N by checki ng the appropri ate box bel ow : 1 - Federal Employer’s I denti fi cati on (FEI ) 3 - Comptroll er’s assi gned Enter the number: No. number 2 - Soci al Securi ty Number Check box i f agency representati ve to be noti fied of assi gned TIN by mail at mail code entered in Secti on VIII. II. PAYEE INFORMATION - (maximum 50 characters, including spaces, per line in this section.) Name of Payee (indi vi dual or busi nes s to be paid) M a i l i n g Ad d r e s s ( w h e r e y o u w a n t t o r e c e i v e p a y m e n t s ) 2 n d L i n e Ad d r e s s ( i f r e q u i r e d ) 3 r d L i n e Ad d r e s s ( i f r e q u i r e d ) 4 t h L i n e Ad d r e s s ( i f r e q u i r e d ) Ci ty State Zip + 4 County Busi ness Telephone No. ( Ar e a c o d e a n d n u m b e r ) : A/ C a n d N u m b e r SIC Code Securi ty Type 0 1 2 Zone Ar e y o u c u r r e n t l y r e p o r t i n g a n y T e x a s t a x o t h e r than unempl oyment (E.G., sal es tax, franchi se tax)? Yes No I f “Yes”, enter Texas Taxpayer No. Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 91 III. BUSINESS INFORMATION (for statistical reporting) - Please check all categories that apply to your business. PROVIDING THE INFORMATION REQUESTED IN THIS SECTION IS VOLUNTARY. Form 4109X Page 2 S m a l l B u s i n e s s E n t e r p r i s e ( i n d e p e n d e n tl y o w n e d a n d o p e r a t e d w i t h f e w e r t h a n 1 0 0 e m p l o y e e s o r l e s s than $1,000,000 annual gross recei pts) Di sadvantaged Busi ness Enterpri se (at least 51% ow ned or controll ed by one or more soci ally di sadvantaged persons) - Check the appropri ate category: Black Hi spani c Am e r i c a n I n d i a n As i a n Am e r i c a n Eski mo Al e u t Other (speci fy); Wo m a n O w n e d B u s i n e s s E n t e r p r i s e ( a t l e a s t 5 1 % o w n e d o r c o n t r o l l e d b y w o m e n ) Other Busi ness Enterpri se (an enterpri se not descri bed i n one of the three categori es show n above) FPS USE ONLY Bus. Desc. IV. OWNERSHIP CODES (For Initial Set-up only) - Check ONLY ONE code by the appropriate ownership type that applies to you or your business and enter any required additional information. I - I n d i v i d u a l R e ci p i e n t ( n o t o w n i n g a b u s i n e s s ) Ag e n c y N o . E-State Empl oyee - Enter agency number of employi ng agency: S-Sol e Ow nershi p of Business - Enter ow ner’s name and Soci al Securi ty No. Ow ner’s Name 2 P- Partnershi p - Enter two partner’s names and SSNs. I f partner i s corporati on, use corporati on’s Federal Empl oyer’s Identifi cati on (FEI ) number. Partner 1 - Name Partner 2 - Name SSN / FEI SSN / FEI Soci al Securi ty No. T- Texas Corporati on A- P r o f e s s i o n a l As s o c i a t i o n checked) C- Professi onal Corporati on O- Out-of-state Corporati on G- Government Enti ty U - S t a t e Ag e n c y / U n i v e r s i t y F - F i n a n c i a l I n s ti t u t i o n R - F o r e i g n ( o u t o f U . S . A. ) N - O t h e r ( e x p l a i n ): E n t e r T X C h a r t e r N o . ( I f T , A, o r C i s c h e c k e d ) Texas Charter No. E n t e r T X C h a r t e r N o . ( I f T , A, o r C i s E n t e r T X C h a r t e r N o . ( I f T , A, o r C i s c h e c k e d ) Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 92 V. P A Y M E N T A S S I G N M E N T I N F O R M A T I O N (NOTE: A copy of the assignment agreement between payees must be attached.) As s i g n e e T I N As s i g n m e n t D a t e As s i g n e e N a m e VI. COMMENTS: VII. APPLICANT INFORMATION Telephone No. (inc. A/C) Date Ap p l i c a n t o r Au t h o r i z e d Ag e n t VIII. FPS REPRESENTATIVE INFORMATION Telephone No. (inc. A/C) FPS M ail Code FPS Representati ve Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 93 Form 4109X INSTRUCTIONS        Thi s form i s used to set up ei ther new accounts or addi ti onal mail codes. To change exi sti ng i nformati on, use the TIN Change Request, Form 41 10. I t i s not necessary for the payee to si gn or compl ete thi s form. The FPS Representa ti ve may complete the form for the payee. Pl ease pri nt or type. Do not use dashes w hen enteri ng Soci al Securi ty, Federal Empl oyer’s Identifi cati on (FEI ), or Comptroll er assi gned numbers. Names of I ndivi dual s must be entered fi rst name firs t. Do not enter more than 50 characters, i ncl uding spaces, on any one li ne of the name and address secti on. Onl y the fi rst 50 characters on each li ne will be entered on the computer. Wh e n t h i s f o r m i s u s e d t o s e t u p n e w a c c o u n t s , t h e f o l l o w i n g i n f o r m a t i o n M U S T b e s u p p l i e d : I. II. IV. VIII.  Texas Identif ication Number (may be based on either a FEI , SSN or Comp troller assi gned number) N a m e o f P a y e e ; P a y e e a d d r e s s ( i n cl u d i n g m a i l i n g a d d r e s s , c i t y , s t a t e a n d Z I P C o d e ) Ownership Code FPS Representative Information (name of FPS representati ve, the tel ephone number, and FPS M ail Code ) Wh e n t h i s f o r m i s u s e d t o s e t u p a d d i t i o n a l m a i l c o d e s , t h e f o l l o w i n g i n f o r m a t i o n M U S T b e s u p p l i e d : I. II. VIII. Texas Identif icati on Number (may be based on either a FEI , SSN or Comp troller assi gned number) N a m e o f P a y e e ; P a y e e a d d r e s s ( i n cl u d i n g m a i l i n g a d d r e s s , c i t y , s t a t e a n d Z I P C o d e ) FPS Representative Information (name of FPS representati ve, the tel ephone number, and FPS M ail Code ) OWNERSHIP CODES If the ownership code is: The following information MUST be supplied: E - State Empl oyee ...................... Empl oyee agency number S - S o l e O w n e r . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ow n e r ’ s n a m e a n d S S N ( n o t F E I N u m b e r ) P - P a r t n e r s h i p . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N a m e s o f tw o p a r t n e r s a n d t h e i r S S N ( o r F E I N u m b e r i f t h e partner i s a corporati on) T - Texas Corporati on .................. Texas Charter Number (as i ssued by the Texas Secretary of State) A - P r o f e s s i o n a l As s o c i a t i o n . . . . . . . . T e x a s C h a r t e r N u m b e r ( a s i s s u e d b y t h e T e x a s S e c r e t a r y o f S t a t e ) C - Professi onal Corporati on ....... Texas Charter Number (as i ssued by the Texas Secretary of State ) An a s s i g n m e n t i s t h e l e g a l t r a n s f e r o f a r i g h t t o p r o p e r t y o r p a y m e n t . An a s s i g n m e n t i n v o l v e s a n a s s i g n o r and an assi gnee. The assi gnee i s the party recei vi ng the ri ght to payment . Once an agency receives A mail code should noti ce of an assi gnment, they are l egall y bound to make payment to the assi gnee. Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 94 be set up to generate payments to the assi gnee under the assi gnor’s TI N. a d d i ti o n t o o t h e r s e c t i o n s r e q u i r e d f o r m a i l c o d e s e t - u p s t o a c c o m p l i s h t h i s t a s k . Compl ete Secti on V. i n Risk Analysis Questionnaire Contract Name: ** Contact Name: Contract Number: Contact Phone Number ** Please provide the person’s name and number to contact if additional information is needed. (This form should be completed with each new contract and at each renewal. It will be used by FPS to help assess risk and assign monitoring level.) 1. Do you currently have other contracts with FPS or any other Governmental entity such as federal, state, school district, university, or county? No Yes If yes, please check the appropriate number below: 1 contract 2 contracts 3 to 4 contracts More than 4 contracts Please list other contracts by name and service: Name of Entity You Contract With What Service are you providing in this Contract 2 How long has it been since your last audit by an independent party, such as an annual independent audit, compliance audit, single audit, etc. This does not include the IRS or monitoring visits made by us. Please check the appropriate time-period below: Never had one Less than 1 year 1 year 2 years 3 years or more (If applicable, and not previously provided to FPS, please attach a copy of audit) Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 95 3. Type of Related Party Transactions: Does your agency **do business with anyone related by blood or marriage to a member of your Board of Directors; a principal stockholder; or a key employee for the following? purchase/lease/service is provided at no charge from anyone related by blood or marriage to a member of your Board of Directors; a principal stockholder; or a key employee. See 40 TAC § 732.240 (F-H). Yes Yes Yes No No No Non-compensated services Non-routine or non-recurring services Consulting or Management services Yes Yes Yes No No No Building/Leasing Transportation Labor **Do business refers to business activities such as purchasing, leasing or obtaining a service even if the 4. The percentage of total expenditures paid out to Subcontractors in a fiscal year, if applicable. Not Applicable 0% 20% or less 21% to 40% more than 40% EXPERIENCE OF MANAGEMENT STAFF AND KEY PERSONNEL Experience with Fiscal and/or Program Components of Federal and/or State Contracted Programs Less than 2 years 2 years or more Total Experience in Providing the Type of Service Being Contracted 0 to 12 months 13 to 35 months 36 to 59 months 60 or more months Less than 2 years 2 years or more 0 to 12 months 13 to 35 months 36 to 59 months 60 or more months 0 to 12 months 13 to 24 months More than 24 months Tenure with your Agency (Business) 0 to 12 months 13 to 24 months More than 24 months Position Staff or Owner Providing Direct Delivery Services Accounting [Owner, Bookkeeper, Billing Tech, Comptroller, Chief Financial Officer, Business Mgr, etc.] Signature of Person Providing Information Title Date Texas Department of Family and Protective Services Provider Enrollment Amended Release Date 12-1-04 Parent / Caregiver Training PEN-2004-020-09-CPS Page 96