State of California--Health and Human Services Agency California Department of Public Health DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT I. Identifying Information Name of entity D/B/A Address (number, street) City State ZIP code CLIA number Taxpayer ID number (EIN) Telephone number ( II. ) Answer the following questions by checking "Yes" or "No." If any of the questions are answered "Yes," list names and addresses of individuals or corporations under "Remarks" on page 2. Identify each item number to be continued. YES NO A. Are there any individuals or organizations having a direct or indirect ownership or control interest of five percent or more in the institution, organizations, or agency that have been convicted of a criminal offense related to the involvement of such persons or organizations in any of the programs established by Titles XVIII, XIX, or XX? ......................................................................................................................... Are there any directors, officers, agents, or managing employees of the institution, agency, or organization who have ever been convicted of a criminal offense related to their involvement in such programs established by Titles XVIII, XIX, or XX? ...................................................................................... Are there any individuals currently employed by the institution, agency, or organization in a managerial, accounting, auditing, or similar capacity who were employed by the institution's, organization's, or agency's fiscal intermediary or carrier within the previous 12 months? (Title XVIII providers only) ........... Ì Ì B. Ì Ì C. Ì Ì III. A. List names, addresses for individuals, or the EIN for organizations having direct or indirect ownership or a controlling interest in the entity. (See instructions for definition of ownership and controlling interest.) List any additional names and addresses under "Remarks" on page 2. If more than one individual is reported and any of these persons are related to each other, this must be reported under "Remarks." NAME ADDRESS EIN B. Type of entity: Ì Sole proprietorship Ì Unincorporated Associations Ì Partnership Ì Corporation Ì Other (specify) ______________________ C. If the disclosing entity is a corporation, list names, addresses of the directors, and EINs for corporations under "Remarks." Are any owners of the disclosing entity also owners of other Medicare/Medicaid facilities? (Example: sole proprietor, partnership, or members of Board of Directors) If yes, list names, addresses of individuals, and provider numbers. .......................................................................................................... NAME ADDRESS D. Ì Ì PROVIDER NUMBER LAB 1513 (7/07) American LegalNet, Inc. www.FormsWorkFlow.com YES NO IV. A. Has there been a change in ownership or control within the last year? ....................................................... If yes, give date. ___________________________________________ B. Do you anticipate any change of ownership or control within the year?....................................................... If yes, when? ______________________________________________ C. Do you anticipate filing for bankruptcy within the year?................................................................................ If yes, when? ______________________________________________ V. Is the facility operated by a management company or leased in whole or part by another organization?.......... If yes, give date of change in operations. ___________________________ VI. Has there been a change in Administrator, Director of Nursing, or Medical Director within the last year?......... VII. A. Is this facility chain affiliated? ...................................................................................................................... (If yes, list name, address of corporation, and EIN.) Name EIN Ì Ì Ì Ì Ì Ì Ì Ì Ì Ì Ì Ì Address (number, name) City State ZIP code B. If the answer to question VII.A. is NO, was the facility ever affiliated with a chain? (If yes, list name, address of corporation, and EIN.) Name EIN Address (number, name) City State ZIP code Whoever knowingly and willfully makes or causes to be made a false statement or representation of this statement, may be prosecuted under applicable federal or state laws. In addition, knowingly and willfully failing to fully and accurately disclose the information requested may result in denial of a request to participate or where the entity already participates, a termination of its agreement or contract with the state agency or the secretary, as appropriate. Name of authorized representative (typed) Title Signature Date Remarks LAB 1513 (7/07) American LegalNet, Inc. www.FormsWorkFlow.com