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Effective Date: 
5/2017

Documents

Instructions

Updated: 5/2017

Purpose

Form 2030 is used to:

  • summarize Texas Health and Human Services Commission’s (HHSC’s) participation in a contract and serve as an information worksheet for the purchase of service contract; and   
  • identify and limit the amount of funds allocated to a contract.

Procedure

Number of Copies

HHSC staff complete an original and three copies of Form 2030 for the contractor and each subcontractor before submitting the proposed contract package to the contractor for signature. HHSC staff keep one copy for the contract file.

Transmittal

HHSC staff send the original and two copies of Form 2030 as part of the proposed contract package to Legal Services staff. 

Form Retention

Retain Form 2030 in accordance with the records retention requirements in the HHS System Contract Management Handbook.

Detailed Instructions

Contract Number — Enter the contract number assigned by HHSC.

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

Section I - Legal Entity Information

Name of Legal Entity — Enter the full legal name of the entity, exactly as it was chartered, 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 Business As (d/b/a/) Name — If applicable, enter the d/b/a 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 area code and telephone number of the legal entity.

Contractor Representative — Enter the name of the individual authorized to sign the contract with HHSC. The contractor representative may be the owner or an authorized representative.

Title — Enter the title of the contractor representative.

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

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

Title of Contact Person — 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, 09-01-2017 through 08-31-2018.

Budget Name — Enter CMPAS.

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

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

Estimated Budget Amount — Enter the estimated budget amount received from the Regional Budget analyst.

Estimated Contract Total — Enter the estimated budget amount.

Section III - Service

Program Activity Name and Code — Already entered on form.

Service Activity Name and Code — Already entered on form.

Section IV - Individual Information

1. Estimated Number of Individuals to be Served — Enter the estimated number of individuals to be served.

2. Projected Units of Service Types — Check each of the projected units of service types to be provided by the contractor.

3. Geographical Area Served — Describe the geographic area (region, county) where the named service is to be provided.

4. Basis of Payment — Check appropriate box.