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Disclosures

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Instructions for completing the Disclosures page.

Select the Application Type from the left navigation menu.

Note, this is only required for ITPs who are not related to the Clients on the Client Panel.

You must answer “Yes” or “No” as it pertains to you for each of the questions included on this page. Your answers should address all past and current actions as applicable. If you answer” Yes”, you will be required to provide additional information about your disclosure.

Sanction” is defined as recoupment, payment hold, imposition of penalties or damages, contract cancellations, exclusion, debarment, suspension, revocation, or any other synonymous action.

Have you ever been sanctioned (as defined above) in any state or federal program? Select Yes or No

If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each action:

Date (Approximate Date Allowed) - Enter the Date

State Where the Incident Occurred – Select the State from the available drop-down menu

Program Affected – Enter the Program Affected

Agency Taking the Action – Enter the name of the Agency taking action against you

Action Taken – Enter the Action Taken for the sanction.

If disclosure is for a prior Exclusion, provide Reinstatement documentation from HHSC/OIG and attach to this page

If you have more than one response, you can select Add Response to save the current response and bring up a new template for your next response.

Is there an outstanding warrant for your arrest?Select Yes or No

If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each charge or conviction:

Date (Approximate Date Allowed) - Enter the Date

State Where the Incident Occurred – Select the State from the available drop-down menu

County - Select the County from the available drop-down menu

Court – Select the Court from the available drop-down menu

Case/Cause Number(s) – Enter the Case/Cause number(s)

Charge – Enter the information on the Charge against you

Explanation/Details – Provide a detailed explanation of the charges against you

Attach all relevant documentation for the cause of the outstanding warrant to this page. If unable to provide documentation, explain why and where it can be obtained.

If you have more than one response, you can select “Add Response” to save the current response and bring up a new template for your next response.

Are you currently subject to court-ordered child support payments?Select Yes or No

Are you currently behind 30 days or more on court ordered child support payments? Select Yes or No

If you selected "Yes”, you must explain the details in the additional field provided below the question. Your explanation must include the details of how Past-Due obligations will be met.

Attach all relevant documentation for the proof of compliance to repayment, along with a payment plan, to this page. If unable to provide documentation, explain why and where it can be obtained.

If you have more than one response, you can select “Add Response” to save the current response and bring up a new template for your next response.

Make a selection from the drop-down menu in order to associate each attachment to a question. If you have attachments that you have added to this page, select the drop-down menu to associate each attachment to the corresponding question.

Click Save.

Access the left navigation and select the next available page to continue entering your application.

This page is not applicable for Maintenance selection. Please continue to the next page.

This page is not applicable for Update selection. Please continue to the next page.