Effective Date: 
12/2017

Documents

 

Instructions

Updated: 6/2009

 

Purpose

Form 2032 captures information necessary to properly identify consumer funds to be escheated to the state of Texas.

 

Procedure

When to Prepare

Form 2032 is completed when consumer funds are submitted to the Texas Health and Human Services (HHS) for escheatment to the state. Form 2032 accompanies a check made payable to HHS for the total amount of consumer funds submitted.

Form Retention

The provider should retain a copy of Form 2032 for record-keeping purposes.

 

Detailed Instructions

Section 1: Provider Information

Provider Type — Check the applicable box to indicate the type of provider.

Provider Name — Enter the legal name of the entity. Include the "doing business as" (DBA) name, if applicable.

Vendor Number — Enter the facility's vendor number, if applicable.

Contract Number — Enter the HHS contract number.

Mailing Address — Enter the street (or P.O. Box), city, state and ZIP code.

Provider Contact Name — Enter the name of the provider staff to contact for more information.

Contact Area Code and Telephone Number — Self-explanatory

 

Section 2: Reason for Escheatment

Check the applicable box. If Deceased/Discharged Consumer is checked, you must complete Section 3 for each consumer you submit funds for to HHS. If the Pooled Trust Fund Bank Account Overage box is checked, enter the amount of overage in the block provided.

 

Section 3: Consumer Information

Consumer Name — Enter the consumer's first name, middle initial and last name.

Date of Birth — Enter the date of birth as month/day/year (mm/dd/yyyy).

Social Security No. — Self-explanatory.

Amount of Funds — Enter the dollar amount of funds submitted.

Date of Death/Discharge — Enter date of death/discharge as mm/dd/yyyy.

Last Known Forwarding Address of Consumer — Enter the street (or P.O. Box), city, state and ZIP code for the discharged consumer. If not known, enter “none.” Enter “n/a” for a deceased consumer.

Name of Guardian/Legally Authorized Representative (LAR) — Self-explanatory. If not known, enter “unknown.”

Guardian/LAR Address — Enter street (or P.O. Box), city, state and ZIP code for guardian/LAR. If not known, enter “unknown.”

Repeat if funds for more than one consumer are submitted.

Note: The enclosed check amount must equal the total amount of funds indicated in Section 3 plus any trust fund bank account overage noted in Section 2.

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