Client Services Contracting

Forms

This page contains Texas Department of Health (TDH) legacy forms that are used to maintain client services grant contracts.

Claims Processing Unit Forms

Please direct questions about the following TDH legacy forms to the Accounting Section, Claims Processing Unit, phone (512) 458-7435.

Form #B-13, State of Texas Purchase Voucher

Purpose: To request monthly reimbursement using a State of Texas Purchase Voucher.
Form #B-13 (51 KB, Word format)
Form #B-13 instructions (21 KB, PDF format)

Form #B-13A, Match/Reimbursement Certification

Purpose: Supporting schedule to be completed and submitted with Reimbursement Vouchers where contractor match is required. Updated 6/2003.
Form #B-13A (41 KB, Word format)
Form #B-13A instructions (21 KB, PDF format)

Form #EB-13X, Supporting Schedule for Title X Reimbursement Vouchers

Purpose: Supporting schedule to be completed and submitted with Title X Reimbursement Vouchers. Updated 10/2007.
Form #EB-13X (45 KB, Excel format)

Form #GC-4a (269a), Financial Status Report

Purpose: To report on a quarterly basis, current and cumulative financial information (i.e., expenditures, program income, etc.) in comparison to the approved contract budget. Form revised 01/2005.
Form #GC-4a (269a) (52 KB, Excel format)

Form #GC-10 (270), Request for Advance or Reimbursement

Purpose: This financial status report is usually required annually for contracts paid on a fee-for-service basis. It reflects total program outlays and DSHS's share of reimbursements. Form revised 12/2002.
Form #GC-10 (270) (231 KB, PDF format)

Contract Oversight and Support Section Forms

Please direct questions about the following TDH legacy forms to the Contract Oversight and Support Section, phone (512)�8-7432.

Form #GC-11, Nonexpendable Personal Property

Purpose: To report on an annual basis equipment purchased through DSHS contracts.
Form #GC-11

In-Kind (Volunteer) Professional Services (Pro-Forma Invoice)

Purpose: Form for backup documentation to support in-kind contributions.
In-Kind (Volunteer) Professional Services (Pro-Forma Invoice) (68 KB, Word format)

Client Services Contracting Unit Forms

Form #EF29-12391, Vendor Information

Purpose: To report to Client Services Contracting Unit (CSCU) any changes to contractor's address, contact person, or signature authority. Form revised 2/2006.
Form #EF29-12391 (412 KB, Word format)

Contract Forms

The following forms are generated as part of your contract. Please direct questions about them to CSCU, phone (512)�8-7470, mail code 6103, email .

• Form #EF29-11961, Nonprofit Board of Directors and Executive Director Assurances
  Purpose: Commitment to ensuring adequate management practices and internal controls, and active involvement of the board in contract oversight activities. Form revised 2/2006.
  Form #EF29-11961 (73 KB, Word format)
• Form #EF29-12390, Contract Budget/Revised Budget
  Purpose: To provide information concerning a budget revision or a contract amendment. Form revised 2/2006.
  Form #EF29-12390 (48 KB, Word Format)
• Form #29-12389, Child Support Certification
  Purpose: To certify that the proprietor, partner, shareholder or owner with an ownership interest of at least 25% is not more than 30 days delinquent in paying child support.�(This form is not applicable to a governmental entity or a non-profit corporation). Form revised 2/2006.
  Form #29-12389 (4 KB, Word format)
• Form #HCFA-1513, Disclosure of Ownership and Control Interest Statement
  Purpose: To disclose direct or indirect ownership interests amounting to an ownership interest of 5% or more in the disclosing entity.�(Applicable to programs funded by Titles V, XVIII, XIX, and XX.)
  Form #HCFA-1513 (236 KB, PDF format)
• Form #29-12374, Certification Regarding Lobbying
  Purpose: To certify that funds will not be used for lobbying activities or for influencing certain federal contracting and financial transaction. (This form applies to contracts exceeding $100,000.) Form revised 2/2006.
  Form #29-12374 (23 KB, Word format)
• Form #EF29-12414, Contractor抯 Request for Revision (CRR)
  Purpose: A formal amendment document will be required under the revised GPs in most case, but for some smaller contract amendments the Contract Revision Request Form may be used. Form revised 10/9/2007.
  Form #EF29-12414 (45 KB, Word format)

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Last Updated November 2, 2007