Form 3681

See full list on hhs. Note:The information reported on this form is subject to verification by HHSC contract staff. Doing Business As (DBA)– Enter name of DBA, if applicable. Facility Physical Address– Enter the physical address of the facility.

Assisted Living Facility License No. Licensed Capacity– Enter the licensed capacity, if applicable. The most secure digital platform to get legally binding, electronically signed documents in just a few seconds.

Available for PC, iOS and Android. Start a free trial now to save yourself time and money! Taxpayer Identification No. Enter the nine-digit federal employer identification number (FEIN) for business entities and the Social Security number for individuals.

Base Station Physical Address— Self-explanatory. HHSC Region— Enter the number of the HHSC region for which you wish to provide services. A list of counties by service region can be viewed by clicking on List of Counties by Service Region at the end of these instructions. Proposed Rate— Enter the rate the legal entity offers to provide ERS under contract with HHSC. The rate offered cannot exceed the maximum rate for the HHSC ERS program.

Private-Pay Rates— Check the appropriate box to indicate whether the legal entity provides ERS to private-pay customers. If Yes, enter in the table the rates charged private-pay customers for the same services (equipment and monitoring) the legal entity proposes to provide HHSC under contract. If a monthly equipment fee is charge indicate whether the fee is for use of the equipment or for purchase of the equipment.

If the monthly equipment fee is for purchase of the equipment, indicate. Complete the subcontractor information table if the legal entity uses any subcontractors to install or monitor ERS equipment. If a person who installs or monitors ERS equipment is not a bona fide employee of an agency, the person is a subcontractor. Note:Attach copies of agreements or contracts for all subcontractors. The owner or authorized representative of the legal entity identified in Section must certify the information provided on the form , as well as all attachments, is true and correct.

I request verification and acceptance of Global Direct mailings at this location. If checked complete boxes below. Residential Care (RC) and Adult Foster Care (AFC) Community Services Contract Application – Addendum A. Renewal Application with Education Compliance Form Broker Renewal Fee: $2Salesperson Renewal Fee: $1(Use a Windows-based PC with MS Internet Explorer for best viewing experience) User ID Print out receipt page for your records. Download a sample today!

These Accuride products may also be of interest. Legal Name of Entity 2. Note: consult with Accuride engineering to determine if the products below are appropriate for your application. Complete this form to request Driver License records (including your personal information on those records).

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Specific Instructions Enter your social security number as it appears on your social security card. Building - Class Structures. All Class Structures must be filed.

Due to the Covid problems and the higher than expected volume being experienced by Rebates International, their turnaround time unfortunately is currently running about weeks from the time they receive your submission.