Form 5510 Natcep PDF Details

Form 5510 is a form used by the IRS to provide notification of an election to claim tax treaty benefits. This form can be used by taxpayers who are claiming a reduced rate of tax under a tax treaty. The form must be filed with the IRS within 30 days after the date of the election. Taxpayers who wish to take advantage of a reduced rate of tax available through a tax treaty should use Form 5510 to notify the IRS of their intent. The form must be filed within 30 days after making the election, so it is important to act quickly if you think you may qualify for treaty benefits. Contact an accountant or lawyer if you have any questions about whether you should file Form 5510 or how to do so. If there's one thing that can make filing your taxes less painful, it's knowing that you're getting every break possible - and that's where Form 5510 comes in! If you're eligible for a reduced rate of tax under your country's tax treaty with the US, using this form is your way of notifying the IRS

Form NameForm 5510 Natcep
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other names5510 NATCEP hhsc dps tx online form

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Texas Department of Aging

Nurse Aide Training Program

Form 5510-NATCEP

and Disability Services

July 2013



Request to Take the Competency Evaluation Program (CEP)



Based on Approved Nurse Aide Training Out of State


I.Use this form to request approval to take the CEP in Texas if you have:

successfully completed at least 100 hours of training at a NATCEP in another state within the preceding 24 months, but have not taken the competency evaluation or been placed on a Nurse Aide Registry in another state;

not completed the CEP or have been placed on the Nurse Aide Registry in another state; and

met CEP requirements listed at §94.11(c)(2)-(3) of the Licensing Standards for Nurse Aides. No individual listed as unemployable on the Employee Misconduct Registry (EMR) or who has been found to have a conviction of a criminal offense listed in Texas Health and Safety Code §205.006 will be eligible for the CEP. Chapter 250 and a list of convictions can be found at:

Nurse Aide Training Program staff will complete the EMR check. However, individuals requesting to take the CEP must request a criminal history check from the Texas Department of Public Safety (DPS). For instructions on how an individual can obtain a criminal history check, contact your local DPS office or visit the website: You must submit your criminal history results along with this application to receive approval to take the test.

II.Complete Items A through Q (type or fill out electronically) A. Name (Last, First, Middle)


Maiden Name

C. Other Surnames






Social Security No.

E. Date of Birth (mm/dd/yyyy)






Address (Street, City, State, ZIP Code)







Home Area Code and Telephone No.

H. Daytime Area Code and Telephone No.

I.Name of Facility, if employed

J.Address of Facility (Street, City, State, ZIP Code)

K.Name of Training Program

L.Address of Training Program (Street, City, State, ZIP Code)

M.Dates of Training (mm/dd/yyyy)





N. Are you on the Nurse Aide Registry in another state?

O. If yes, which state(s)?




P. Signature

Q. Date (mm/dd/yyyy)

III.Applicant must attach proof of successful completion of a Nurse Aide Training Program approved in another state. This proof must be a photocopy of an original certificate of completion that has been notarized as a true and exact copy of an unaltered original.

IV. If the name on the certificate is different than the name in Item II-A, applicant must attach proof of name change, such as a photocopy of a marriage license, divorce paper or legal name change document.

Form 5510-NATCEP

Page 2/07-2013

V.The Department of Aging and Disability Services (DADS) will review the request and send a written notice of approval, deficiency or disapproval. When approved, applicant will receive a:

letter stating eligibility to take the CEP,

copy of the skills checklist, and

test application and instructions.

VI. Applicant is responsible for finding a location to take the CEP. If possible, find:

an approved facility that offers you employment and testing, or

an approved facility or nurse aide training program that volunteers to test you.

Visit our website,, to help locate a training program near your area.

VII. Return completed form and the attachments requested in Items III and IV to:

Department of Aging and Disability Services







Nurse Aide Training Program








Mail Code: E-420








P.O. Box 149030








Austin, Texas

































DADS Office Use Only



















Rev on













Photo of Cert




Inc on

















Inc sent on













State called




Disappr on













Talked to




Disappr sent on













On Registry




Appr on

















Appr sent on












If yes, request written summary








Took CEP







































OBRA Approved Prog



















Date Prog Apprd



















Called by



















Name Change

Department of Aging and Disability Services

Nurse Aide Training Program

Mail Code E-420

P.O. Box 149030

Austin, Texas 78714-9030

With a few exceptions, you have the right to request and be informed about the information that the Department of Aging and Disability Services (DADS) obtains about you. You are entitled to receive and review the information upon request. You also have the right to ask DADS to correct information that is determined to be incorrect (Government Code Sections 552.021, 552.023, 559.004). To find out about your information and your right to request correction, contact the Regulatory Services Nurse Aide Training Program at 512- 438-2017.

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