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Disclosure Of Or Change In Ownership And Control Interest Statement Form. This is a Washington form and can be use in Department Of Social And Health Services Statewide.
Tags: Disclosure Of Or Change In Ownership And Control Interest Statement, Washington Statewide, Department Of Social And Health Services
DISCLOSURE OF OR CHANGE IN OWNERSHIP AND CONTROL INTEREST STATEMENT Completion and submission of this form is a condition of participation and full and accurate disclosure of ownership and financial interest is required. A failure to submit the requested information may result in a refusal by the State agency to enter into an agreement or contract with the individual and/or entity or in termination of any existing agreements. Please answer all questions as of the current date. If additional space is needed please use an attached sheet. Federal statutes and regulations clearly prohibit States from paying for items or services furnished, ordered or prescribed by excluded persons. States are required to search the exclusions database not only by the name of an entity seeking to participate in the program, but also by the name of any owner or managing employee. I. Identifying Information OWNER TYPE (check one) Individual Ownership Ownership DOING BUSINESS AS FEDERAL TAX ID/SSN Organization MINORITY WOMEN OWNED BUSINESS ENTERPRISE (MWOBE): ORGANIZATION NAME II. Ownership and Control Information List each office and/or individual, organization, corporation or entity that has direct or indirect ownership or controlling interest, separately or in combination, amounting to an ownership interest of 5% or more of the provider entity. Attach additional pages as necessary. LAST NAME SSN/TIN LAST NAME SSN/TIN LAST NAME SSN/TIN LAST NAME FIRST NAME SSN/TIN ADDRESS FIRST NAME ADDRESS FIRST NAME ADDRESS FIRST NAME ADDRESS List those persons named that are related to each other (spouse, parent, child, or sibling) NAME RELATIONSHIP 1 American LegalNet, Inc. www.FormsWorkFlow.com III. Subcontractor Information List each person with an ownership or control interest in any subcontractor in which the disclosing entity has direct or indirect ownership of 5% or more. Attach additional pages as necessary. NAME AND TITLE SSN/TIN PERCENTAGE SSN/TIN PERCENTAGE ADDRESS NAME AND TITLE ADDRESS Does any owner of the disclosing entity also have an ownership or controlling interest 5% or more in any other entity? NAME AND TITLE SSN/TIN PERCENTAGE SSN/TIN PERCENTAGE ADDRESS NAME AND TITLE ADDRESS IV. Criminal Offenses List each officer and/or individual who has ownership or control interest in the disclosing entity, or is an agent or managing employee of the disclosing entity and has been convicted of a criminal offense related to that person’s involvement in any program under Medicare, Medicaid or Title XVIII, XIX, or XX, since the inception of those program. Attach additional pages as necessary. NAME AND TITLE SSN/TIN PERCENTAGE SSN/TIN PERCENTAGE ADDRESS NAME AND TITLE ADDRESS V. Suspension or Debarment Have you, any of your employees, or, any individual who has an ownership or controlling interest in the disclosing entity ever been placed on the federal Office of the Inspector General, Health and Human Services (OIG/HHS) exclusions list or otherwise been suspended or debarred from participation in Medicare, Medicaid or Title XVIII, XIX, or XX services programs. If yes, list each person below. Attach additional pages as necessary. The current list to excluded individuals can be found at: http://exclusions.oig.hhs.gov/search.aspx NAME AND TITLE SSN/TIN PERCENTAGE SSN/TIN PERCENTAGE ADDRESS NAME AND TITLE ADDRESS 2 American LegalNet, Inc. www.FormsWorkFlow.com VI. Status Changes Is a change of ownership anticipated within the next year? Yes No Is this facility operated by a management company or leased in whole or party by another organization? Yes No Yes No If yes, list date of change in operations: Has there been a past bankruptcy or do you anticipate filing for bankruptcy within the next year? If yes, when? List each of the Board of Directors of the disclosing entity. Attach additional pages as necessary. NAME AND TITLE SSN/TIN PERCENTAGE SSN/TIN PERCENTAGE ADDRESS NAME AND TITLE ADDRESS 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 appropriate state agency. By signature I certify that the information provided within, is true and correct and I fully understand the consequences as explained above. SIGNATURE AND TITLE OF INDIVIDUAL COMPLETING THIS FORM DATE 3 American LegalNet, Inc. www.FormsWorkFlow.com