Client Services Contracting Forms

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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) 776-7435.

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. Instructions are included. Updated 5/2014.
Form #B-13A (77 KB, XLS format)

Form #GC-4a (269a), Financial Status Report
Purpose: To report on a periodic basis, current and cumulative financial information (i.e., expenditures, program income, etc.) in comparison to the approved contract budget. Form revised 07/2009. PLEASE NOTE: When opening the FSR workbook, a security warning regarding macros might appear. If so, simply click the “Disable Macros” button and continue.  In other instances, you might be notified that macros were automatically disabled.  Simply click “OK” and continue. This FSR workbook is fully functional WITHOUT the use of macros.
Form #GC-4a (269a) (254 KB, Excel format)

Instructions for 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)

Form #EF29-12503, Vendor Direct Deposit Authorization Form
Purpose: Used by vendors/payees to authorize direct deposit of payments and advanced payment notification (for return to the paying state agency).
Form #EF29-12503 – Vendor Direct Deposit Authorization Form (313 KB PDF format)

Travel Office Forms/Links

Rates

Hotel Contracts

Bing "Online Mileage Mapping"

In-State Lodging Meals and Mileage Rates, October 2009-August 2010

Traveler's Resources

Travel Allowance Guide - Resource (PDF)

Forms

Travel Form Descriptions

TR Form (2012), Travel Request Authorization Form, for travel on or after October 01, 2012 (85KB Word) 12/2009.

Travel Voucher Form (2010), Travel Reimbursement for DSHS employees on or after January 01, 2010 (300KB Excel) 02/2010.

B-19, Travel to Agency-Sponsored Training Seminar (32KB Word)

B-71 Word, Multiple Activity Travel Report (168KB)

B-71 Excel, Multiple Activity Travel Report (46KB)

Form 74-176, For vendors receiving direct deposit payment (s) from the State of Texas or for State of Texas employees receiving travel reimbursement payment(s) by direct deposit.

Travel Voucher Disclaimer (Excel)

Sample Wording for Claiming Point-to-Point Mileage

Travel Reimbursement System (TRS)

Travel Reimbursement System URL

TRS Users Guide (PDF) v1.10

Common TRS Mistakes (PDF)

TRS Mileage Only Users Guide (PDF)

Contract Oversight and Support Section Forms

Please direct questions about the following TDH legacy forms to the Contract Oversight and Support Section, phone (512) 458-7432.

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

Please direct questions about the following forms to CSCU, phone (512) 458-7470, email CSCU Customer Support .

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.
Vendor Information Update and Maintenance (12/2009)
Form #EF29-12391 (12/2008)

Computer Purchase Requirements for DSHS Contractors

Minimum DSHS Computer Specifications (03/2009)Suggested Minimum computer equipment specifications required for computer equipment purchases approved by the Department of State Health Services.

Minimum DSHS Laptop Computer Specifications (03/2009)Suggested Minimum laptop computer equipment specifications required for computer equipment purchases approved by the Department of State Health Services.

Vendor Certification for Computer Equipment Purchased by DSHS Contractor (03/2009) – This vendor certification may be completed by the vendor and attached to the vendor's computer equipment quote and specifications. This is not required, but is useful if purchasing clone or rebuilt computers.

Contract Forms

The following forms are generated as part of your contract. Please direct questions about them to CSCU, phone (512) 458-7470, mail code 1886, email CSCU Customer Support.

  • Cost Reimbursement Budget Template - Full Costs (12/2009) - The total amount budgeted on the detail budget category forms must reflect funding from all sources that support the project. This budget template is intended to accompany the RFP template for competitive procurements from sub-recipients with cost reimbursement budgets.

  • Form #EF29-12390, Contract Budget/Revised Budget
    Purpose: To provide information concerning a budget revision or a contract amendment. Also know as GC-9/9A. Form revised 3/2008.
    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 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 #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’s 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 May 22, 2014