Date Of Ownership Change
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Date Of Ownership Change Form. This is a California form and can be use in Department Of Health And Human Services Statewide.
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Tags: Date Of Ownership Change, HS 310, California Statewide, Department Of Health And Human Services
State of California—Health and Human Services Agency
Department of Health Services
DATE OF OWNERSHIP CHANGE
Reply to:
Department of Health Services
Licensing and Certification Program
Centralized Applications Unit
MS 3402
P.O. Box 997413
Sacramento, CA 95899-7413
Re:
(Facility name)
(Facility address—number, street)
(City, state, ZIP code)
We have been advised that you are the new owner(s) of the subject facility.
We wish to make certain that our records correctly show the effective date of the ownership change. This date
should reflect the actual date on which you took charge of the financial management of the facility rather than the
date of sale or date of state license change.
Would you please enter this effective date in the space provided at the bottom of this page. We also request that
you or your representative, and if possible the previous owner, sign this form and return with any other material we
have asked you to return.
Effective date of change of ownership
Signature (for new owner)
Signature (for previous owner)
Name of new owner, partnership, limited liability company, or corporate entity
Name of previous owner, partnership, limited liability company, or corporate entity
HS 310 (2/05)
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