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Dads form 2192-2026

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The document is Form 2192 from the Texas Department of Aging and Disability Services, which serves as a certification regarding licensure requirements for Home and Community Support Services Agencies (HCSSAs). It includes a series of yes/no questions to verify the agency's compliance with licensure criteria, such as holding the correct category of licensure, conducting health surveys, eligibility for renewal, and service provision metrics. The form requires an authorized representative's signature and notarization to confirm the accuracy of the information provided.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the legal name of your entity at the top of the form. This is crucial for identification purposes.
Next, list all relevant Home and Community Support Services Agency (HCSSA) license numbers in the designated field.
Proceed to answer each yes/no question regarding licensure requirements. Ensure you read each question carefully and select the appropriate response.
After completing the questions, review your answers for accuracy. This step is vital as misrepresentation can lead to serious consequences.
Finally, sign and date the form in the designated area. Type or print your name as the authorized representative below your signature.

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Versions	Form popularity	Fillable & printable
2013	4.8 Satisfied (102 Votes)

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