Form 1571, Request for Partial Reimbursement for the Cost Installation of a Fire Sprinkler System in a Four-Person Residence

Instructions for Opening a Form

Some forms cannot be viewed in a web browser and must be opened in Adobe Acrobat Reader on your desktop system. Click here for instructions on opening this form.

Documents

Effective Date: 3/2017

Instructions

Updated: 3/2017

PURPOSE

To request partial reimbursement for the cost of installation of a fire sprinkler system in a four-person residence. Rider 32 of the 2016-2017 General Appropriations Act (Article II, House Bill 1, 84th Legislature, Regular Session, 2015) appropriated funds for the Texas Health and Human Services Commission (HHSC) to reimburse Home and Community-based Services (HCS) program providers for up to 50 percent of the cost of installation of a fire sprinkler system in a four-person residence. The rider contains the following additional requirements:

  • the reimbursement amount must not exceed $10,000 per residence;
  • the fire sprinkler system must have been installed after Sept. 1, 2012; and
  • a provider requesting reimbursement must provide documentation to HHSC demonstrating the cost to the provider for the installation.

Additional guidance and information about the application process can be found in Information Letter (IL) 17-07.

When to Prepare

An HCS program provider must submit Form 1571 and the following documentation to HHSC:

  • As required by Texas Administrative Code (TAC), Title 28, Part 1, §34.716, a State Fire Marshal’s Office Form SF041, Contractor’s Material and Test Certification for Aboveground Piping, properly completed by the fire sprinkler installer. The rules governing the licensing of fire sprinkler installation companies require the installation company to provide this document to the owner of the building upon completion of the fire sprinkler installation.
  • If required by 28 TAC §34.716, a State Fire Marshal’s Office Form SF042, Contractor’s Material and Test Certification for Underground Piping, properly completed by the fire sprinkler installer. The rules governing the licensing of fire sprinkler installation companies require the installation company to provide this document to the owner of the building upon completion of the fire sprinkler installation.
  • An invoice or statement for the installation of the fire sprinkler system from the fire sprinkler installation company showing:
    • the date installation was completed, which must be after Sept. 1, 2012;
    • that the name of the program provider on the invoice is the same as the program provider requesting partial reimbursement;
    • the address of the residence in which the system was installed;
    • the total cost of the installation;
    • if the invoice contains multiple charges, which charges are directly associated with the fire sprinkler installation, and documentation that substantiates those stated charges; and
    • the total cost has been paid.
  • If work associated with the installation of the fire sprinkler system is performed by a person or entity other than the fire installation company, an invoice or statement for the work from the person or entity performing the work showing:
    • the date the work was performed, which must be after Sept. 1, 2012;
    • that the name of the program provider on the invoice is the same as the program provider requesting partial reimbursement;
    • the address of the residence in which the work performed;
    • the total cost of the work;
    • if the invoice contains multiple charges, which charges are related to the work associated with the installation of the fire sprinkler and documentation that substantiates those stated charges; and
    • the total cost has been paid.

Note: The required documentation must be emailed to HCSsprinkler@dads.state.tx.us and be received by HHSC by 5 p.m. Central Standard Time on June 30, 2017. The subject line of the email must be the address of the four-person residence, including the city and ZIP code.

Detailed Instructions

HCS Program Provider Name — Enter the name of the entity that contracts with HHSC to provide HCS program services. This must be the same entity shown on the invoice for the sprinkler system.

Contract No. — Enter the contract number for the HCS program provider. This number will begin with a 0.

Component Code — Enter the three-digit component code, which may be letters, numbers or a combination of both.

Contact Person — Enter the contact person for the HCS program provider. This is the person who can answer questions about the request for reimbursement.

Contact Person’s Area Code and Phone No. — Enter the area code and phone number for the contact person.

Contact Person’s Email Address — Enter the email address for the contact person.

Payee Name — Enter the name of the entity to which funds, if any, will be disbursed.

Payee Address — Enter the mailing address of the payee, including the city, state, and ZIP code.

Texas Identification Number —  Enter the TIN, which is a 14-digit number that is based on a person’s Social Security Number (SSN); an entity’s federal Employer Identification Number (EIN); or a Texas Comptroller of Public Accounts “Comptroller-assigned” number for entities without an identifying SSN or EIN. The TIN is referred to as a Vendor ID in the Client Assignment and Registration (CARE) System. A TIN consists of master information and one mail code. A program provider may have multiple mail codes. The mail code used is the location where the payment will be sent.

Example of a TIN: 17622233344000
TIN broken into its components: 1 762223334 4 000
  Prefix SSN/EIN Self-check Digit Mail Code

Address of Four-Person Residence (with Sprinkler System) —Enter the address of the four-person residence, including the city, state, and ZIP code.

Four-Person Residence Location Code — Enter the location code assigned to the four-person residence, through the CARE System.

County in Which Four-Person Residence is Located — Enter the name of the county for the four-person residence.

Signature of Program Provider Contact — Enter the signature of the program provider contact.

Date — Enter the date the form is signed.

For HHSC Use Only — HHSC staff complete, sign and date the rest of the fields on the form.