Effective Date: 
6/2017

Documents

 

Instructions

Updated: 6/2017

 

Purpose

  • To summarize HHSC's participation in a contract and serve as an information worksheet for the purchase of service contract.
  • To identify and limit the amount of funds allocated to a contract.

 

Procedure

Number of Copies

HHSC staff completes an original and one copy of Form 2029 for the contractor.

Transmittal

HHSC staff manager routes the original Form 2029 with the contract or contract amendment as a part of the proposed contract package to HHSC Legal System Contracting. HHSC staff sends a copy of Form 2029 and the contract or contract amendment to the contractor.

Form Retention

Retain Form 2029 in accordance with the records retention requirements in the HHS System Contract Management Handbook.

 

Detailed Instructions

Contract/Vendor Number — Enter the assigned contract number.

Region Number — Enter the two-digit number of the region responsible for the contract.

Section I – Legal Entity Information

Legal Name of Legal Entity — Enter the full legal name of the entity, exactly as it was charted, filed, registered or otherwise legally declared, applying to become a contractor or subcontractor. If the applicant is an individual, enter the full legal name of the individual.

Contract Effective Date — Enter the month, day, and year the contract is effective.

Doing Buisness As (d/b/a) Name — If applicable, enter the d/b/a(s) relevant to this legal entity.

Contract Termination Date — Enter the month, day, and year the contract terminates.

Mailing Address of Legal Entity — Enter the mailing address of the legal entity.

Area Code and Telephone Number — Enter the telephone number of the legal entity.

Person Authorized to Sign Contract — Enter the name of the person authorized to sign the contract with HHSC.  The person authorized to sign the contract may be the owner or the owner’s authorized representative as indicated on the Form 2031, Governing Authority Resolution - Business Organization, or Form 2031-G, Governing Authority Resolution – Governmental Entity.

Title — Enter the title of the person authorized to sign the contract.

Ownership — Check the box to show if the contractor is a public agency; a private, non-profit agency; or a private, for-profit agency.

Charter Number — Enter the charter of incorporation or certificate of authority number on file with the Secretary of State's office.

Federal Tax ID Number — Enter the 9-digit employer identification number (EIN) assigned to the legal entity by the Internal Revenue Service.  If the legal entity is a sole proprietorship or individual who does not have an EIN, enter the owner's or individual's Social Security number (SSN).

Contact Person— Enter the name of the person with whom HHSC staff should communicate about this contract.

Contact Person’s Title — Enter the title of the contact person.

Area Code and Telephone Number — Enter the area code and telephone number of the contact person.

Section II – Summary of Payment

Effective Payment Dates — Enter, for each budget, the beginning and ending dates for which payment is authorized. The dates are to be inclusive, for example, 1-1-17 through 6-30-17.

Budget Name — Enter the name for each budget as shown on Form 2030, Budget for Purchase of Services. If there is no budget, enter N/A (unit rate only).

Unit Rate — Enter the approved unit rate (unit rate payment only).

Estimated Number Eligible Units — Enter the agreed number of units of service to be delivered by the contractor to eligible individuals.

Estimated Local Funds — Enter the required amount of certified local resources for each budget. If none, enter 0.

Estimated HHSC Funds — Enter the department's share of the total budget.

Estimated Budget Amount — Enter the sum of estimated local and estimated HHSC funds. For unit rate contracts, this is the product of the unit rate multiplied by the number of eligible units.

Estimated Contract Total — Enter the sums of estimated local funds, estimated HHSC funds, and estimated budget amount in the appropriate boxes.

Percent of Contract — Enter the total estimated local funds percent and the HHSC percent. The sum of these entries must be 100%.

Section III – Service

Program Activity Name and Code — HHSC staff can obtain the Program Activity Name and the Program Activity Codes from the Regional Budget Officer.

Service Activity Name and Code — HHSC staff can obtain the Service Activity Name and the Service Activity Codes from the Regional Budget Officer.

 Section IV – Individual Information

1. Total Number of Individuals to be Served — Enter the estimated number of individuals to be served and check the time period (per day, per week, per month).

2. Number of Eligible Individuals to be Served — Enter the estimated number of eligible individuals to be served in the named service area during the specified time period by the contractor or subcontractor.

3. Unit of Service — Enter the unit of service used to measure contract performance, such as half-day of service, hour of service, and day of service.

4. Number of Units of Service to All Individuals — Enter the estimated number of units of service to be provided for all individuals in the named service area by the named contractor or subcontractor.

5. Number of Units of Service to Eligible Individuals — Enter the estimated number of units of service for eligible individuals to be provided in the named service area by the named contractor or subcontractor.

6. Geographic Area Served — Describe the geographic area (city, county, ZIP code, area, etc.) where the named service is to be provided.

7. Basis of Payment — Check appropriate box.

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