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., TEXAS FORM K: CHILD SUPPORT CERTIFICATION <br />1 q)mtriwnl - i <br />V', 'il,dr i ie a?lli tii•ttu e-ti <br />Department of State Health Services <br />Child Support Certification <br />The Texas Family Code, §231.006, VTCA places certain restrictions on child support obligors. Contracts with <br />governmental entities or nonprofit corporations are not subject to §231.006. <br />The contractor identified below is not a governmental entity or a nonprofit corporation and certifies to the <br />following: <br />1. The contractor is: (check one) <br />? An individual or sole proprietor, or <br />? A business entity (corporation, partnership, joint venture, limited liability company, <br />association, etc.) <br />2. The contractor certifies the following is a complete list of the names and social security numbers of either <br />(A) the individual or sole proprietor who is the contractor or (B) each partner, shareholder, or owner with <br />an ownership interest of at least 25% of the contractor/business entity: (attach additional sheet if <br />necessary). <br />(A) Printed Name: <br />Social Security Number: <br />(B) Printed Name: <br />Social Security Number: <br />3. Under the Texas Family Code, §231.006, VTCA the contractor certifies that the individual or business <br />entity named in this contract, bid, or application is not ineligible to receive the specified grant, loan, or <br />payment and acknowledges that this contract may be terminated and payment withheld if this certification <br />is inaccurate. A child support obligor who is more than 30 days delinquent in paying child support or a <br />business entity in which the obligor (who is more than 30 days delinquent) is the sole proprietor, partner, <br />shareholder, or owner with an ownership interest of at least 25% is not eligible to receive the specified <br />grant, loan or payment. The contractor understands that it is the contractor's responsibility to verify <br />whether a child support obligor who is more than 30 days delinquent is the sole proprietor, partner, <br />shareholder or owner with an ownership interest of at least 25%. <br />4. Printed Name of Contractor: <br />Printed Name of Authorized Representative: <br />Signing this Certification: <br />Signature of Authorized Representative: <br />Date: <br />Page 41 RFP# EMS/LPG - 0328.1