Form 4116 is used to organize data for entry into the Texas Health and Human Services Commission (HHSC) accounting system, for the HHSC comptroller and management approved unencumbered purchases. Form 4116 can also be used as part of an internal control process and to document required approvals.
Using Form 4116 for the wrong type of purchases will lead to processing delays and after-the-fact purchase orders.
Note: Staff who make purchases outside applicable statutes, rules, policies and procedures may be held personally responsible for those purchases.
When to Prepare
HHSC employees should only use Form 4116 for the following:
- Manager-approved employee non-travel reimbursements (made per Health and Human Services (HHS) procurement policy);
- Notary application fees;
- Regulated utilities;
- Postage; and
- HHS Printing services. For information, visit https://www.dshs.texas.gov/hhsprinting/ (link is external).
Shaded areas should be left blank.
Agency No. — 529
Agency Name — Texas Health and Human Services Commission
Current Document No. — Not Applicable (N/A) and leave blank.
Texas Identification No. (TIN) — It is required to enter the 14-digit number assigned by the state comptroller. If this is the first time to use this vendor, complete and submit Comptroller Form AP-152, Application for Texas Identification Number, or Comptroller Form 74-157, Payee Change Request, to the Accounts Payable/TINS Unit to have a TIN set up. Form AP-152 and Form 74-157 can be emailed to the HHSC TINS Requests Folder at TIN.Requests@hhsc.state.tx.us. If requests are sent by interagency mail, send to Attn: TINS, Mail Code E-411.
PDT — N/A
Document Amount — It is required to enter the total dollar value of the invoice.
Payee Name/Address — It is required to enter the name and address, including ZIP code, of the vendor. This is usually the remittance address on the invoice. The payee may be an individual, hospital, company, facility or organization. If the payee is an individual, enter the first name, middle initial and last name. Note: This information will be used in a window envelope to mail the payment and/or direct deposit notification to the vendor. The name and address should match the TIN information in Item 4.
Agency Use — Use this field if Form 4116 is submitted for an employee reimbursement, including the TIN of the company the employee paid.
Note: Once an invoice number is assigned and used, do not use it again for another payment. Example: 0001
- Ref Doc — N/A
- SFX — N/A
- Confid. — N/A
- TC (Transaction Code) — N/A
- Original Payment Date — N/A
- PCA — N/A
- AY — This is required and is the year payment was budgeted. If not budgeted, it would be the fiscal year the payment should be charged. Only the current fiscal year (FY) and two prior FYs are available. Example: If 2018 is the current FY, payments can only be made to 2017 and 2016. The FY begins September 1 of each year and ends August 31.
- COBJ (Comptroller object code) — N/A unless already known.
- Account — Enter the six-digit agency account.
- Amount — It is required to enter the amount for this line item only.
- R — Required if the line amount is negative.
- APPN — N/A
- Fund — N/A
- Invoice Received Date — It is required to enter the date that a valid invoice was first received at HHSC.
- Delivery Date — Enter the date (or end date in a range of dates) that the goods or services were received and considered payable according to established contract terms and conditions for the payment.
- Payment Due Date — N/A
- Requested Payment Date — N/A
- Interest Control — N/A
- Reason — N/A
- Invoice No. — If no invoice number is given, request one from the vendor. If the vendor refuses to provide one, create an invoice number. Do not create invoice numbers using the following sequences:
- Vendor name
- TIN or Social Security number
- Any other sequence that may be easily replicated in other units, divisions or state supported living centers
- Description — It is required to describe the cost for each line of the purchase if there are different types of purchases on the form.
- MM/YY of Ser. — It is required to enter the month and year to which the goods/services were received. If payment is for a service, use the last date of the service period.
- Dept ID — It is required to enter the three-digit region/division department that is to be charged for the expense.
- Program — It is required to enter the three-digit program (PAC) to be charged for the expense.
- Speedchart — Enter the five-digit speedchart number, if known.
SER/DEL Date — It is required to enter the service date, range of dates or delivery date (month, day and year) the purchased goods were delivered or the services were performed.
Description of Goods or Services — It is required to enter a clear, concise description of goods purchased or services performed.
SCOR Contract No. and 11b. SCOR Service Dates — It is required to enter the System of Contract Operation and Reporting (SCOR) [replaced Health and Human Services Contract Administration and Tracking System (HCATS) 9-1-17] contract number and service dates if there is a contract. In most instances, Form 4298, Purchase Request, would be required if a contract exists (instead of Form 4116).
Quantity — It is required to enter the quantity of items.
Unit Price — It is required to enter the price or cost per unit of the items purchased.
Amount — This equals the quantity multiplied by the unit price or rate.
Vendor Certification — Complete on certified claims.
Telephone (Area Code and No.) — Enter the number for the vendor.
Approval — N/A unless required by the program area.
Contact Name and Telephone (Area Code and No.) — It is required to enter the HHSC contact name and telephone number. Note: The contact person must be able to answer questions regarding the payment request.
Entered By — N/A
Certification Statement — N/A
Approved/Mail Code/Telephone/Date — Completing these fields is required. Only authorized HHSC staff given approval authority to enter into or approve a purchase agreement may sign. Staff may not authorize payments if they are the requestor, payee or beneficiary of the services. Two signatures of approval are required. Both lines must be filled out each by a different approver.