PEN Application and Contract, with instructions



DFPS uses the PEN Application and Contract (2280PEN) to create a contract between DFPS and a Contractor for the performance of services that were solicited using the Provider Enrollment (PEN) procurement method. The PEN Application and Contract, Form 2280PEN is included as an attachment to the PEN solicitation. Under §5 of the 2280PEN, DFPS must indicate where the services will be provided. The Contractor will be required to provide services in the geographical area specified in the solicitation, most frequently consistent with a DFPS region. APPLICATION AND CONTRACTIn State Adoption ServicesHHS0000013Identification InformationLegal Name of Entity/Applicant FORMTEXT ?????Doing Business As (DBA) NameIf different from Legal Name FORMTEXT ?????Attach a copy of Assumed Name CertificateVendor ID Number FORMTEXT ?????Federal ID Number – If different from Vendor ID FORMTEXT ?????Type of Applicant – Check “√” appropriate box(es) and attach documentation as indicated FORMCHECKBOX Individual/Sole Proprietor FORMCHECKBOX Limited Liability Company (LLC) Attach a copy of the Articles of Formation FORMCHECKBOX CorporationType of Corporation: FORMCHECKBOX For Profit FORMCHECKBOX Non-ProfitState of Incorporation: FORMTEXT ?????Charter Number: FORMTEXT ?????Attach a copy of Certificate of Incorporation FORMCHECKBOX PartnershipType of Partnership: FORMCHECKBOX Limited FORMCHECKBOX GeneralAttach a copy of Partnership Agreement.If applicable, also attach a copy of the Signatory AssignmentContact InformationOffice Address (Street-Suite #) FORMTEXT ?????Office Address (City, State, Zip) FORMTEXT ?????Mailing Address (P.O. Box) If different from above FORMTEXT ?????Mailing Address (City, State, Zip) If different from above FORMTEXT ?????Phone- Primary Office FORMTEXT ?????Fax- Primary Office FORMTEXT ?????E-Mail- Primary Office FORMTEXT ?????Name-Primary Contact Person FORMTEXT ?????Title-Primary Contact Person FORMTEXT ?????Phone-Primary Contact Person FORMTEXT ?????Alternate Phone-Primary Contract Person FORMTEXT ?????E-Mail- Primary Contract Person FORMTEXT ?????Name- Person Authorized to Sign Contract FORMTEXT ?????Title- Person Authorized to Sign Contract FORMTEXT ?????Phone- Person Authorized to Sign Contract FORMTEXT ?????Alternate Phone- Person Authorized to Sign Contract FORMTEXT ?????E-Mail- Person Authorized to Sign Contract FORMTEXT ?????Name-Person Responsible for Billing FORMTEXT ?????Title- Person Responsible for Billing FORMTEXT ?????Phone- Person Responsible for Billing FORMTEXT ?????Alternate Phone- Person Responsible for Billing FORMTEXT ?????E-Mail- Person Responsible for Billing FORMTEXT ?????DFPS will send contract-related communications to the primary contact listed above. The Contractor must maintain and monitor at least one active e-mail address for the receipt of contract-related communications from DFPS. Services to Be ProvidedContractor must provide all In State Adoption Services specified in Provider Enrollment HHS0000013.Service Area - StatewideThe children served by In State Adoption Services are located throughout the eleven (11) DFPS geographic regions in the State of Texas. Proof of LicensureAs specified in the open enrollment document in subsection 1.5.4, an agency seeking a contract with DFPS for Adoption Services must be licensed to perform adoption in Texas. Include with this Application for Enrollment the agency's license.Experience SummaryAs specified in the open enrollment document in subsection 2.12.1.1, an agency (or the agency staff member assigned to a pursuant contract) seeking a contract with DFPS for In State Adoption Services must have completed at least six (6) Special Needs Adoptions. Attach to this application a written summary describing the Agency's Experience, including:The Agency’s qualifications and experience in at least six (6) Special Needs Adoptions in terms of placement and supervision;The Agency’s staff’s qualifications and experience in Special Needs Adoptions in terms of placement and supervision, including the; Supervisor Narrative of Experience; Supervisor Proof of Education (Professional license/ copy of degree);Case Manager Narrative of Experience; andCase Manager Proof of Education;The Agency’s subcontractors’ qualifications and experience in Special Needs Adoptions in terms of placement and supervision, if applicable. InsuranceReview the minimum insurance requirements in PEN §2.12.4. Applicants must meet all requirements as outlined. Indicate in the table below, if requirement is met:Commercial General Liability FORMCHECKBOX Yes FORMCHECKBOX NoApplicant does not have required Commercial General Liability insurance, but will obtain within the timeframe defined in the PEN: FORMCHECKBOX Yes FORMCHECKBOX NoCommercial Crime FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A*Applicant does not have required commercial crime insurance, but will obtain within the timeframe defined in the PEN: FORMCHECKBOX Yes FORMCHECKBOX NoBusiness Automobile Liability Insurance FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A - DFPS clients will not be transported FORMCHECKBOX Applicant will transport DFPS clients. Describe the purpose of client transportation: FORMTEXT ?????Applicant does not carry Business Automobile Liability Insurance for its employees or subcontractors, but will obtain within the timeframe defined in the PEN: FORMCHECKBOX Yes FORMCHECKBOX NoAttach a copy of the Form 4736, Certificate of Insurance (COI) or equivalent (ACORD Certificate of Insurance, or a copy of the policy) for each policy currently in force and referenced in the table above. Form 4736 has been approved by the Texas Department of Insurance and is the preferred form of insurance verification.*Business entities with no employees and hospitals are exempt from crime policy insurance requirement.For Employees and SubcontractorsApplicant’s organization requires individual professional employees and subcontractors to secure their own Professional Liability Insurance: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AIncorporation by ReferenceThe following documents are incorporated into the Contract for all purposes:DFPS Vendor Uniform Contract Terms and Conditions, Form 5645V, located in Package 6 of procurement HHS0000013; DFPS Special Conditions, Form 5622V, located in Package 6 of procurement HHS0000013; Provider Enrollment HHS0000013, including all addenda and attachments;Application and Contract Form 2280PEN, as completed by the Contractor, including all addenda and attachments; andEach Service Authorization Form 2054, prepared by DFPS.Order of PrecedenceThe Contractor will provide the services and deliverables described and required by all the documents listed in this Section. In the event of conflicts or inconsistencies between documents, such conflicts or inconsistencies will be resolved by reference to the documents in the following order of precedence:This PEN Application and Contract, 2280PEN, and any amendments thereto;DFPS Vendor Uniform Contract Terms and Conditions, Form 5645V, located in Package 6 of procurement HHS0000013;DFPS Special Conditions, Form 5622V, located in Package 6 of procurement HHS0000013;Provider Enrollment HHS0000013 and any amendments thereto; Each Service Authorization Form 2054 prepared by DFPS; and Application and Contract Form 2280PEN, as completed by the Contractor, including all addenda and attachments, and any amendments thereto.Certification and SignatureI certify that the information provided in this application is, to the best of my knowledge, complete and accurate; that the named legal entity has authorized me, as its representative, to submit this application; and that the legal entity complies with all terms of this Provider Enrollment.By signing this PEN Application and Contract, applicant certifies that if a Texas address is shown as the address of the applicant, applicant qualifies as a Texas Resident Bidder as defined in Texas Administrative Code, Title 34, Part 1, Chapter 20.DFPS will post all official communication regarding this PEN on the Electronic State Business Daily (ESBD). DFPS reserves the right to revise the PEN at any time. Contractors must comply with any changes, amendments, or clarifications posted to ESBD. It is the responsibility of the Contractor to periodically check the ESBD for updates to the procurement. The Contractor’s failure to periodically check the ESBD will not release the Contractor from “addenda or additional information” resulting in additional costs to meet the requirements of the PEN.The undersigned representative agrees to all the terms and conditions specified in the Contract and by signing below agrees to execute the terms and conditions of the Contract upon receipt of a 2054 from the Department. Signature of Authorized RepresentativeDateName of Authorized Representative (Printed) FORMTEXT ?????Title of Authorized Representative (Printed) FORMTEXT ?????DFPS Approval Signature:Signature of Authorized DFPS RepresentativeDateName of Authorized DFPS Representative (Printed) FORMTEXT ?????Title of Authorized DFPS Representative (Printed) FORMTEXT ?????Contract Information – For DFPS Use ONLYDFPS will complete the information below once Application is screened, reviewed, and accepted for contract.NoticesAny notice required or permitted under this contract by the Contractor to DFPS must be in writing and submitted to the DFPS address below:DFPS Office Address (Street Address, Suite #, or P.O. Box, City, State and Zip Code) FORMTEXT ?????Contract TermContract Number (DFPS staff will complete) FORMTEXT ?????The initial contract period will begin on the effective date stated below, with the total contract term not to exceed sixty (60) months.Effective Date of Contract FORMTEXT ?????End Date of ContractAugust 31, 2020 ................
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