Supervised Visitation Services PEN HHS0000096 2280PEN Application and Contract (021314)

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APPLICATION AND CONTRACT

1. Identification Information Legal Name of Applicant Doing Business As (DBA) Name If different from Legal Name Attach a copy of Assumed Name Certificate Vendor ID Number Federal ID Number – If different from Vendor ID

2. Type of Applicant – Check “√” appropriate box(es) attach documentation as indicated Individual/Sole Proprietor Corporation Type of Corporation: For Profit Non-Profit State of Incorporation: Charter Number: Attach a copy of Certificate of Incorporation Partnership Type of Partnership: Limited General Attach a copy of Partnership Agreement. If applicable, also attach a copy of the Signatory Assignment

3. Contact Information Office Address (Street-Suite #) Office Address (City, State, Zip)

Mailing Address (P.O. Box) Mailing Address (City, State, Zip) If different from Office Address above If different from Office Address above

Phone- Primary Office Fax- Primary Office E-Mail- Primary Office

Name-Primary Contact Person Title-Primary Contact Person

Phone-Primary Contact Person Alternate Phone-Primary Contract E-Mail- Primary Contract Person Person Supervised Visitation Services PEN HHS0000096 2280PEN Application and Contract (021314)

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Name- Person Authorized to Sign Contract Title- Person Authorized to Sign Contract

Phone- Person Authorized to Sign Alternate Phone- Person E-Mail- Person Authorized to Sign Contract Contract Authorized to Sign Contract

Name-Person Responsible for Billing Title- Person Responsible for Billing

Phone- Person Responsible for Alternate Phone- Person E-Mail- Person Responsible for Billing Billing Responsible for Billing

Any notice required or permitted under this Contract by DFPS to the contractor must be in writing and sent to the primary contact information noted in this 2280PEN, Application and Contract. At all times, Contractor will maintain and monitor at least one active electronic mail (e- mail) address for the receipt of Contract-related communications from DFPS. It is the Contractor's responsibility to monitor this e-mail address for Contract related information.

4. Services to Be Provided Contractor must provide all Supervised Visitation Services specified in Provider Enrollment 530 - 13 - 0102

5. Region to be Served Applicant must mark with a “√” next to the Region(s) to be served.

Region One (1) Region Seven (7) Region Two (2) Region Eight (8) Region Three (3) Region Nine (9) Region Four (4) Region Ten (10) Region Five (5) Region Eleven(11) Region Six (6)

6. Insurance

6.1. Review the minimum insurance requirements in PEN §2.8 Insurance Standards. Applicants must meet all requirements as outlined. Indicate in the table below, if requirement is met: Supervised Visitation Services PEN HHS0000096 2280PEN Application and Contract (021314)

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Applicant does not have required Commercial Commercial General Liability General Liability insurance, but will obtain within the PEN defined timeframe: Yes No Yes No Applicant does not carry Professional Liability Professional Liability Insurance Insurance for our employees or subcontractors, but will obtain within the PEN defined timeframe: Yes No Yes No N/A Applicant does not have required commercial Commercial Crime crime insurance, but will obtain within the PEN defined timeframe: Yes No Yes No

Attach a copy of the Form 4736, Certificate of Insurance (COI) or equivalent (ACORD Certificate of Insurance, for example) for each policy currently in force and referenced within the table.

Form 4736 is the preferred verification because this DFPS Certificate of Insurance has been approved by the Texas Department of Insurance.

6.2. For Employees and Subcontractors

Applicant’s organization requires individual professional employees and subcontractors to secure their own Professional Liability Insurance:

Yes No N/A

7. Incorporation by Reference

The following documents are incorporated into the Contract for all purposes:  DFPS Uniform Contract Terms and Conditions  Provider Enrollment 530-13-0102, including all addenda and attachments  Attachment A-3 as completed by the Contractor, including all addenda and attachments  Each Service Authorization Form 2054 prepared by DFPS

8. Order of Precedence

The 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:

8.1. This Contract 2280PEN and any amendments thereto; 8.2. DFPS Uniform Contract Terms and Conditions; Supervised Visitation Services PEN HHS0000096 2280PEN Application and Contract (021314)

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8.3. Provider Enrollment 530 - 13 - 0102 and any amendments thereto; 8.4. Each Service Authorization Form 2054 prepared by DFPS; and 8.5. Attachment A-3 as completed by the Contractor, including all addenda and attachments, and any amendments thereto.

9. Certification

I 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 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.

I have attached Form 2031, Signature Authority Designation authorizing me to enter into contracts on behalf of this legal entity.

HHSC will post all official communication regarding this PEN on the Electronic State Business Daily (ESBD). HHSC 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 Representative Date

Name of Authorized Representative (Printed) Title of Authorized Representative (Printed) Supervised Visitation Services PEN HHS0000096 2280PEN Application and Contract (021314)

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10. Contract Information – For DFPS Use ONLY

DFPS will complete the information below once Application is screened, reviewed, and accepted for contract.

10.1. Notices

Any 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;-Suite #; or P.O. Box)

10.2. Contract Term

Contract Number (DFPS staff will complete) 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 End Date of Contract Supervised Visitation Services PEN HHS0000096 2280PEN Application and Contract (021314)

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Service Delivery Area Counties To Be Served – Region 1 Choose the counties within the Region where services will be provided. Check (“√ ”) the box in front of the county name. Choose a single county or any combination of counties. ***CPS Designated Underserved County Regional Counties ☐ Armstrong*** ☐ Hockley*** ☐ Bailey*** ☐ Hutchinson*** ☐ Briscoe*** ☐ King*** ☐ Carson*** ☐ Lamb*** ☐ Castro*** ☐ Lipscomb*** ☐ Childress*** ☐ Lubbock ☐ Cochran*** ☐ Lynn*** ☐ Collingsworth*** ☐ Moore*** ☐ Crosby*** ☐ Motley*** ☐ Dallam*** ☐ Ochiltree*** ☐ Deaf Smith*** ☐ Oldham*** ☐ Dickens*** ☐ Parmer*** ☐ Donley*** ☐ Potter ☐ Floyd*** ☐ Randall ☐ Garza*** ☐ Roberts*** ☐ Gray*** ☐ Sherman*** ☐ Hale*** ☐ Swisher*** ☐ Hall*** ☐ Terry*** ☐ Hansford*** ☐ Wheeler*** ☐ Hartley*** ☐ Yoakum*** ☐ Hemphill*** Supervised Visitation Services PEN HHS0000096 2280PEN Application and Contract (021314)

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Service Delivery Area Counties To Be Served – Region 2 Choose the counties within the Region where services will be provided. Check (“√ ”) the box in front of the county name. Choose a single county or any combination of counties. ***CPS Designated Underserved County Regional Counties ☐ Archer*** ☐ Kent*** ☐ Baylor*** ☐ Knox*** ☐ Brown*** ☐ Mitchell*** ☐ Callahan*** ☐ Montague*** ☐ Clay*** ☐ Nolan*** ☐ Coleman*** ☐ Runnels*** ☐ Comanche*** ☐ Scurry*** ☐ Cottle*** ☐ Shackelford*** ☐ Eastland*** ☐ Stephens*** ☐ Fisher*** ☐ Stonewall*** ☐ Foard*** ☐ Taylor*** ☐ Hardeman*** ☐ Throckmorton*** ☐ Haskell*** ☐ Wichita*** ☐ Jack*** ☐ Wilbarger*** ☐ Jones*** ☐ Young*** Supervised Visitation Services PEN HHS0000096 2280PEN Application and Contract (021314)

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Service Delivery Area Counties To Be Served – Region 3 Choose the counties within the Region where services will be provided. Check (“√ ”) the box in front of the county name. Choose a single county or any combination of counties. ***CPS Designated Underserved County Regional Counties ☐ Collin ☐ Johnson*** ☐ Cooke*** ☐ Kaufman*** ☐ Dallas ☐ Navarro*** ☐ Denton ☐ Palo Pinto*** ☐ Ellis*** ☐ Parker*** ☐ Erath*** ☐ Rockwall*** ☐ Fannin*** ☐ Somervell ☐ Grayson*** ☐ Tarrant ☐ Hood*** ☐ Wise*** ☐ Hunt*** Supervised Visitation Services PEN HHS0000096 2280PEN Application and Contract (021314)

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Service Delivery Area Counties To Be Served – Region 4 Choose the counties within the Region where services will be provided. Check (“√ ”) the box in front of the county name. Choose a single county or any combination of counties. ***CPS Designated Underserved County Regional Counties ☐ Anderson ☐ Marion ☐ Bowie ☐ Morris*** ☐ Camp*** ☐ Panola*** ☐ Cass*** ☐ Rains*** ☐ Cherokee ☐ Red River*** ☐ Delta ☐ Rusk ☐ Franklin*** ☐ Smith ☐ Gregg ☐ Titus ☐ Harrison ☐ Upshur ☐ Henderson ☐ Van Zandt ☐ Hopkins ☐ Wood*** ☐ Lamar Supervised Visitation Services PEN HHS0000096 2280PEN Application and Contract (021314)

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Service Delivery Area Counties To Be Served – Region 5 Choose the counties within the Region where services will be provided. Check (“√ ”) the box in front of the county name. Choose a single county or any combination of counties. ***CPS Designated Underserved County Regional Counties ☐ Angelina ☐ Polk*** ☐ Hardin ☐ Sabine*** ☐ Houston*** ☐ San Augustine*** ☐ Jasper*** ☐ San Jacinto*** ☐ Jefferson ☐ Shelby*** ☐ Nacogdoches ☐ Trinity*** ☐ Newton*** ☐ Tyler*** ☐ Orange Supervised Visitation Services PEN HHS0000096 2280PEN Application and Contract (021314)

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Service Delivery Area Counties To Be Served – Region 6 Choose the counties within the Region where services will be provided. Check (“√ ”) the box in front of the county name. Choose a single county or any combination of counties. ***CPS Designated Underserved County Regional Counties ☐ Austin*** ☐ Liberty*** ☐ Brazoria*** ☐ Matagorda*** ☐ Chambers*** ☐ Montgomery ☐ Colorado*** ☐ Walker*** ☐ Fort Bend ☐ Waller*** ☐ Galveston*** ☐ Wharton ☐ Harris Supervised Visitation Services PEN HHS0000096 2280PEN Application and Contract (021314)

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Service Delivery Area Counties To Be Served – Region 7 Choose the counties within the Region where services will be provided. Check (“√ ”) the box in front of the county name. Choose a single county or any combination of counties. ***CPS Designated Underserved County Regional Counties ☐ Bastrop*** ☐ Hill*** ☐ Bell ☐ Lampasas*** ☐ Blanco*** ☐ Lee*** ☐ Bosque*** ☐ Leon*** ☐ Brazos*** ☐ Limestone*** ☐ Burleson*** ☐ Llano*** ☐ Burnet*** ☐ Madison*** ☐ Caldwell ☐ McLennan ☐ Coryell*** ☐ Milam*** ☐ Falls*** ☐ Mills ☐ Fayette*** ☐ Robertson*** ☐ Freestone*** ☐ San Saba*** ☐ Grimes*** ☐ Travis ☐ Hamilton*** ☐ Washington*** ☐ Hays ☐ Williamson Supervised Visitation Services PEN HHS0000096 2280PEN Application and Contract (021314)

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Service Delivery Area Counties To Be Served – Region 8 Choose the counties within the Region where services will be provided. Check (“√ ”) the box in front of the county name. Choose a single county or any combination of counties. ***CPS Designated Underserved County Regional Counties ☐ Atascosa ☐ Karnes ☐ Bandera ☐ Kendall ☐ Bexar ☐ Kerr ☐ Calhoun*** ☐ Kinney ☐ Comal ☐ La Salle ☐ De Witt*** ☐ Lavaca*** ☐ Dimmit ☐ Maverick*** ☐ Edwards ☐ Medina*** ☐ Frio*** ☐ Real ☐ Gillespie ☐ Uvalde*** ☐ Goliad ☐ Val Verde*** ☐ Gonzales*** ☐ Victoria*** ☐ Guadalupe ☐ Wilson*** ☐ Jackson ☐ Zavala*** Supervised Visitation Services PEN HHS0000096 2280PEN Application and Contract (021314)

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Service Delivery Area Counties To Be Served – Region 9 Choose the counties within the Region where services will be provided. Check (“√ ”) the box in front of the county name. Choose a single county or any combination of counties. ***CPS Designated Underserved County Regional Counties ☐ Andrews*** ☐ Mason*** ☐ Borden*** ☐ McCulloch*** ☐ Coke*** ☐ Menard*** ☐ Concho*** ☐ Midland ☐ Crane*** ☐ Pecos*** ☐ Crockett*** ☐ Reagan*** ☐ Dawson*** ☐ Reeves*** ☐ Ector ☐ Schleicher*** ☐ Gaines*** ☐ Sterling*** ☐ Glasscock*** ☐ Sutton*** ☐ Howard*** ☐ Terrell*** ☐ Irion*** ☐ Tom Green ☐ Kimble*** ☐ Upton*** ☐ Loving*** ☐ Ward ☐ Martin*** ☐ Winkler*** Supervised Visitation Services PEN HHS0000096 2280PEN Application and Contract (021314)

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Service Delivery Area Counties To Be Served – Region 10 Choose the counties within the Region where services will be provided. Check (“√ ”) the box in front of the county name. Choose a single county or any combination of counties. ***CPS Designated Underserved County Regional Counties ☐ Brewster*** ☐ Hudspeth*** ☐ Culberson*** ☐ Jeff Davis*** ☐ El Paso*** ☐ Presidio*** Supervised Visitation Services PEN HHS0000096 2280PEN Application and Contract (021314)

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Service Delivery Area Counties To Be Served – Region 11 Choose the counties within the Region where services will be provided. Check (“√ ”) the box in front of the county name. Choose a single county or any combination of counties. ***CPS Designated Underserved County Regional Counties ☐ Aransas*** ☐ Live Oak*** ☐ Bee*** ☐ McMullen*** ☐ Brook***s ☐ Nueces ☐ Cameron ☐ Refugio*** ☐ Duval*** ☐ San Patricio*** ☐ Hidalgo ☐ Starr*** ☐ Jim Hogg*** ☐ Webb*** ☐ Jim Wells*** ☐ Willacy*** ☐ Kenedy ☐ Zapata*** ☐ Kleberg*** Supervised Visitation Services PEN HHS0000096 2280PEN Application and Contract (021314)

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:

Satellite Offices and Additional Office Information: Please provide a schedule in the table(s) below indicating days and times routinely available to provide services at each service location. These represent only routine days and times. Applicant will be expected to adjust schedule to accommodate the needs of clients and DFPS. Refer to PEN Section 2.5 for additional information. Use additional copies of this section, as necessary, to provide complete information.

Name of Applicant/Contractor

1. Service Delivery Address City, State, Zip Phone Fax Contact Person E-mail

HOURS DAY From To From To Example 7 AM Noon 2 PM 7 PM Monday Tuesday Wednesday Thursday Friday Saturday Sunday

2. Service Delivery Address City, State, Zip Phone Fax Contact Person E-mail Supervised Visitation Services PEN HHS0000096 2280PEN Application and Contract (021314)

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HOURS DAY From To From To Monday Tuesday Wednesday Thursday Friday Saturday Sunday

3. Service Delivery Address City, State, Zip Phone Fax Contact Person E-mail

HOURS DAY From To From To Monday Tuesday Wednesday Thursday Friday Saturday Sunday Supervised Visitation Services PEN HHS0000096 2280PEN Application and Contract (021314)

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ATTACHMENT A-2 FEE SCHEDULE Supervised Visitation Services

Contractor will bill for appropriate unit of service based on type of service, the site of service delivery, and applicable number of units provided. Additional limits and information regarding fees and payment are within the terms defined in PEN 530-13-0102 §2 Statement of Work and §3 Utilization and Compensation

1. Fees for all service delivery areas except those specified in #2:

Unit Rate Unit Service Service Of Location Other Add On for Code In CPS Service Than CPS Video Recording Office Office Visit Rules Discussion & One 92L $6.25 $7.50 Visitation Planning Time Visitation 92L *Hourly $25.00 $30.00 $5.00 Missed One 92L $12.50 $15.00 Appointments Time Court Related 86H *Hourly $30.00 Services *Billed in fifteen (15) minute increments

2. Fees for all service delivery areas specified below: Visits conducted in Ector (Gardendale, Goldsmith, Odessa and West Odessa), Midland (Midland), Andrews (Andrews and McKinney Acres), Ward (Barstow, Monahans, Thorntonville, Wickett, Grandfalls, and Pyote), and Howard (Coahoma, Forsan, Sand Springs and Webb Village) Counties

Unit Rate Unit Service Service Of Location Other Add On for Code In CPS Service Than CPS Video Recording Office Office Visit Supervised Visitation Services PEN HHS0000096 2280PEN Application and Contract (021314)

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Rules Discussion & One 92L $7.50 $10.00 Visitation Planning Time Visitation 92L *Hourly $30.00 $40.00 $5.00 Missed One 92L $15.00 $20.00 Appointments Time Court Related 86H *Hourly $40.00 Services *Billed in fifteen (15) minute increments

Attachment B Required Forms

Notes

1. Forms can be accessed via the link (hold down the "Ctrl" key while clicking on the link) provided in the column titled "Download" of the Required Forms Table. Save the form Supervised Visitation Services PEN HHS0000096 2280PEN Application and Contract (021314)

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on your computer, and complete the saved form as instructed. 2. Forms must be completed and signed. Note: Review each form in its entirety to ensure that applicable sections are completed. 3. Forms requiring an original signature must be signed and saved in the electronic (pdf) copy. 4. Some forms may include special instructions or clarification provided under the name of the form in the column titled "Name." 5. If a form does not apply to you or your organization, mark the form "N/A", include your operation's name, sign, date, and return the form with response package. Supervised Visitation Services PEN HHS0000096 2280PEN Application and Contract (021314)

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ATTACHMENT B Required Forms Number Name Purpose Download Signature authority 2031 Signature Authority Designation Word designation Disclosure and Consent to Release of Information Regarding Criminal or Abuse/Neglect Release of information regarding criminal history or 2970C [Respondent is required to complete Word DFPS abuse and neglect and return form 2970c only on the history. personnel that will be responsible for initial and ongoing entry of background checks into ABCS.] Request for Criminal History and DFPS History Check Application for requesting [Respondent is required to complete 2971C criminal history and DFPS Word and return form 2971c only on the abuse or neglect history. personnel that will be responsible for initial and ongoing entry of background checks into ABCS.] For vendor to receive direct 4108x Vendor Direct Deposit Authorization Acrobat deposit Application for Texas Identification Application for identification 4109x Word Number/Additional Mailing Address number To determine DFPS's ability Request for Determination of Ability to contract with vendor 4732 4732.docx to Contract based on conflict of interest rules Preferred proof of required DFPS Certificate of Insurance insurance. If not available Applicant may provide 4736 [This Certificate of Insurance has ACORD Certificate of Word been approved by the Texas Insurance, or a copy of the Department of Insurance.] policy for each policy currently in force. List the contracting entity, all service providers, and requested provider Contracting Entity and List of Staff, PCS-102 information on this form. PCS 102 Subcontractors, and Volunteers Find the form by scrolling down to the Supervised Visitation Services Table. Supervised Visitation Services PEN HHS0000096 2280PEN Application and Contract (021314)

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ATTACHMENT B Required Forms Number Name Purpose Download Information Security and Privacy To protect and safeguard Initial Inquiry (SPI) Form agency confidential data for ---- Contractors who access http://www.hhsc.stat agency confidential e.tx.us/about_hhsc/ information. BusOpp/HHS_SPI.p df Form instructions provided. Supervised Visitation Services PEN HHS0000096 2280PEN Application and Contract (021314)

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