Effective Date: 
5/2016

Documents

Instructions

Updated: 5/2016

PROCEDURE
Complete this form in order to:

Transmittal

Mail applications with required documents and the appropriate license fee to:

If sending forms with a payment:

Texas Department of Aging and Disability Services
Accounts Receivable, Mail Code E-411
P. O. Box 149030
Austin, TX 78714-9030

or, for overnight delivery only, deliver applications with required documents and the appropriate license fee to:

Texas Department of Aging and Disability Services
Accounts Receivable, Mail Code E-411
701 West 51st Street
Austin, TX 78751

If sending forms without a payment:

Texas Department of Aging and Disability Services
Regulatory Services, Mail Code E-342
P. O. Box 149030
Austin, TX 78714-9030

or, for overnight delivery only, deliver applications with required documents and does not include a payment:

Texas Department of Aging and Disability Services
Regulatory Services, Mail Code E-342
701 West 51st Street
Austin, TX 78751

Note to facilities applying for a Title 19 Medicaid contract: applicants for a Title 19 Medicaid contract are required to submit a separate application to Provider Services, Institutional Services Section. This application form is available from and submitted to Provider Services, Institutional Services Section. If you need further assistance with your Title 19 Medicaid contract application, call the Institutional Services Section at 512-438-3556 and ask to speak to a contract specialist.

GENERAL INSTRUCTIONS

Pursuant to Texas Administrative Code, Title 40 (40 TAC), Chapter 19, §19.204(a)(1), the applicant must complete this application in accordance with these instructions. Full disclosure of the information requested in the application and instructions is mandatory.

Pursuant to Chapter 242 of the Texas Health and Safety Code (H&SC) and 40 TAC, Chapter 19, the Texas Department of Aging and Disability Services (DADS) considers the following in evaluating licensure criteria:

  • background, qualifications and experience;
  • character;
  • compliance history;
  • financial ability to operate;
  • ability to comply with minimum standards of medical care, nursing care and financial condition;
  • ability to comply with any applicable state or federal standard; and
  • any additional information as requested of the following:
    • the applicant/license holder;
    • a partner, officer, director or managing employee of the applicant or license holder;
    • a person who owns or who controls the owner of the physical plant of a facility in which the nursing facility operates or is to operate (controlling person); and
    • a controlling person as defined in Chapter 242 of the HSC, §242.0021.

A controlling person [controlling entity] is defined as a person who has the ability, acting alone or in concert with others, to directly or indirectly influence, direct or cause the direction of the management, expenditure of money, or policies of an institution or other person. Thus, a controlling person includes:

  • a management company, landlord or other business entity that operates or contracts with others for the operation of an institution;
  • any person who is a controlling person of a management company or other business entity that operates an institution or that contracts with another person for the operation of an institution; and
  • any other individual who, because of a personal, familial or other relationship with the owner, manager, landlord, tenant or provider of an institution, is in a position of actual control or authority with respect to the institution, without regard to whether the individual is formally named as an owner, manager, director, officer, provider, consultant, contractor or employee of the facility.

A controlling person as described above does not include a person, such as an employee, lender, secured creditor or landlord, who does not exercise any influence or control, whether formal or actual, over the operation of an institution.

Pursuant to 40 TAC, §19.204(a)(2) and §19.1918, if information contained within the application and attachments changes after the applicant submitted the information to DADS, the applicant must notify DADS within 30 days of the change and submit new application documents.

For Assistance: To facilitate the application process, the application will be assigned to a licensure/certification specialist upon receipt. If, after consulting these application instructions, you need further assistance with your licensure/Title 19 Medicaid certification application, call the Licensing and Credentialing Section at 512-438 2630 and ask to speak to a licensure/certification specialist.

DETAILED INSTRUCTIONS

Item 1 — Facility Information

Facility Name — Enter the name of the facility exactly as it appears on the filed Certificate of Assumed Business Name. Do not use abbreviations. Note: If an applicant chooses to not file a Certificate of Assumed Business Name, the applicant's name will be used as the facility name on the license.

National Provider Identifier No. — Enter the National Provider Identifier (NPI) number assigned by the Centers for Medicare and Medicaid Services (CMS) and/or by the state survey agency, if applicable, in the first box. If the nursing facility has multiple NPIs assigned to distinct units of the nursing facility, enter all applicable NPIs.

Facility Identification No. — Enter the facility identification number issued by the state of Texas (leave blank if not yet issued).

Physical Address — Street, City, State, ZIP, County — Self-explanatory.

Facility Area Code and Telephone No. — Self-explanatory.

Facility Area Code and Fax No. — Self-explanatory.

Facility Email Address — Self-explanatory. If no email address, leave blank.

Mailing Address (if different from Physical Address) — Street or P. O. Box, City, State, ZIP — The facility license and other facility correspondence will be mailed to this address. The mailing address must be in the same city as the facility. For towns with no post office, the mailing address may be in the city where the nearest post office is located.

Item 2 — Nursing Facility Administrator (NFA)

Last Name, First Name, Middle Initial, (Jr., Sr., etc.) — Self-explanatory.

Social Security No. (Optional) — Self-explanatory.

NFA License No. — Self-explanatory.

NFA License Expiration Date — Self-explanatory.

NFA's Permanent Address — Street, City, State, ZIP — Enter the facility administrator’s permanent home address. Do not enter the facility address. If the facility administrator’s permanent home address changes, immediately notify the Nursing Facility Administrator Program at 512-438-2015 and submit Form 5522-NFA, Data Change/Duplicate

Regulatory Services Division
Licensing and Credentialing Section
Nursing Facility Administrator Program
Mail Code W-245
Texas Department of Aging and Disability Services
P. O. Box 149030
Austin, TX 78714-9030

NFA's Area Code and Home Telephone No.— If the facility administrator’s home telephone number changes, immediately notify the Nursing Facility Administrator Program at 512-438-2015 and submit Form 5522-NFA, Data Change/Duplicate License Request, to the Nursing Facility Administrator Program at the address shown above.

NFA's Mailing Address (if different from Physical Address) — Street, City, State, ZIP — Do not enter the facility’s mailing address. If the facility administrator’s mailing address changes, immediately notify the Nursing Facility Administrator Program at 512-435-2015 and submit Form 5522-NFA, Data Change/Duplicate License Request, to the Nursing Facility Administrator Program at the address above.

Other Area Code and Telephone No. — Enter an alternate telephone number, including area code, at which the facility administrator can be contacted. Do not enter a home telephone number or the facility’s telephone number. If the facility administrator’s other telephone number changes, immediately notify the Nursing Facility Administrator Program at 512-435-2015 and submit Form 5522-NFA, Data Change/Duplicate License Request, to the Nursing Facility Administrator Program at the address above.

Note: If the facility is presently licensed, and if the administrator is not the same as the administrator listed on the facility’s previous application, check the box for Change of Administrator under Item 3, give the effective date of the change, and submit the applicable fee based on the fee schedule in Item 4 of these instructions.

Form 5522-NFA, Data Change/Duplicate License Request, is available here.

Item 3 — Type of Application

Initial — Check this box to apply for a license to operate a new nursing facility, or to apply for a license due to a lapse in a facility's license. If the applicant has never been issued a license to operate a nursing facility in Texas, submit the license fee for a probationary license only.

  • Three-year license: Initial licenses with an effective date of Sept. 1, 2013, or later will be issued a three-year license.
  • Submit a copy of the required documents as specified in Attachment A: Required Documents by Type of Application.

License Renewal — This box will be checked for you on the DADS preprinted renewal application.

  • Beginning with licenses expiring Sept. 1, 2013, DADS will issue a three-year license to facilities with a facility identification number ending in an odd digit, and issue a two-year license to facilities with a facility identification number ending in an even digit. The license renewal fee for facilities receiving a two-year license will be two-thirds of the current renewal fee. DADS will provide renewal applicants with a payment coupon containing their required renewal fee. DADS will issue three-year renewal licenses to all facilities beginning Sept. 1, 2014.
  • DADS will mail a preprinted application and instructions to the license holders 120 days before the expiration date of the license.
  • Renewal applications must be submitted at least 45 days before the license expiration date. An applicant for license renewal who submits an application during the 45-day period ending on the date the current license expires must pay a late fee of an amount equal to one-half of the total basic renewal fee.
  • If you do not receive a preprinted renewal application or have questions about renewing a license, call Regulatory Services, Licensing and Credentialing at 512-438-2630.
  • DADS will only accept and process preprinted renewal applications.
  • Retain a copy of the completed renewal application for your records.
  • Submit a copy of the required documents as specified in Attachment A: Required Documents by Type of Application.

New Medicaid Provider Agreement — Check this box when reapplying for a contract after contract termination.

Medicaid Re-Application — Check this box when applying for recertification after decertification.

Relocation — Check this box to apply for an initial license as a result of a facility relocation.

  • Enter the effective date requested for the relocation. During the application review process, DADS may change the effective to reflect the effective date approved by DADS.
  • Three-year license: Initial licenses with an effective date of Sept. 1, 2013, or later will be issued a three-year license.
  • Submit a copy of the required documents as specified in Attachment A: Required Documents by Type of Application.

License Capacity Increase or Decrease — Check this box to apply for a change in the number of licensed beds.

  • Enter the effective date requested for a license capacity decrease.
  • For a license capacity increase, do not enter an effective date. The effective date of the capacity increase will be determined by an on-site survey.
  • Submit a copy of the required documents as specified in Attachment A: Required Documents by Type of Application.

Change of Ownership — Check this box to apply for a nursing facility license as a new license holder, or for nursing facility Title 19 Medicaid certification, as a result of a change of ownership. If the applicant has never been issued a license to operate a nursing facility in Texas, submit the license fee applicable for a probationary license only.

  • Change of Ownership licenses with an effective date of Sept. 1, 2013, or later will be issued a three-year license.
  • Enter the effective date requested for the ownership change. During the application review process, DADS may change the effective date to reflect the effective date approved by DADS.
  • Submit a copy of the required documents as specified in Attachment A: Required Documents by Type of Application.
  • The application must be submitted at least 30 days before the anticipated date of sale or other transfer of ownership (see 40 TAC §19.210). The outgoing owner must notify DADS in writing 30 days before the intended change of ownership.

Change of ownership is defined as follows:

  1. Sole proprietor. A change of ownership occurs if:
    1. the sole proprietor who is licensed to operate the facility changes; or
    2. the sole proprietorship that is licensed to operate the facility is sold or otherwise transferred to an entity that is not licensed to operate the facility.
  2. General partnership (as defined in the Texas Business Organization Code, §1.002). A change of ownership occurs if:
    1. a partner of a general partnership that is licensed to operate the facility is added or substituted;
    2. the partnership that is licensed to operate the facility is sold or otherwise transferred to an entity that is not licensed to operate the facility; or
    3. the partnership that is licensed to operate the facility is terminated.
  3. Limited partnership (as defined in the Texas Business Organization Code, §1.002). A change of ownership occurs if:
    1. a general partner of a limited partnership that is licensed to operate the facility is added or substituted;
    2. ownership of the limited partnership that is licensed to operate the facility changes by 50% or more;
    3. the partnership that is licensed to operate the facility is sold or otherwise transferred to an entity that is not licensed to operate the facility; or
    4. the partnership that is licensed to operate the facility is terminated.
  4. Nonprofit organization. A change of ownership occurs if the nonprofit organization that is licensed to operate the facility is sold or otherwise transferred to an entity that is not licensed to operate the facility.
  5. For-profit corporation or limited liability company. A change of ownership occurs if:
    1. ownership of the business entity that is licensed to operate the facility changes by 50% or more; or
    2. the business entity that is licensed to operate the facility is sold or otherwise transferred to an entity that is not licensed to operate the facility.
  6. City, county, state or federal governmental authority or hospital district /authority. A change of ownership occurs if the governmental entity that is licensed to operate the facility chooses to no longer operate the facility and another entity proposes to become the new operator of the facility.
  7. Trust, living trust, estate or any other entity type not included in paragraphs (1)-(6) of this subsection. A change of ownership occurs if the entity that is licensed to operate the facility is sold or otherwise transferred to an entity that is not licensed to operate the facility.
  8. For all entity types listed in paragraphs (2)-(7). A change of ownership occurs if the federal taxpayer identification number changes.
  9. For license holders that have multiple-level ownership structures, a change of ownership also occurs if any action described in paragraphs (1)-(7) of this subsection occurs at any level of the license holder’s entire ownership structure.

Updates

Change of Administrator — Check this box to report a change of administrator (not previously reported) if the change is being reported with a renewal or change of ownership application.

  • Complete all parts of the application if the change of administrator is being reported with a renewal or change of ownership. Note: If you are reporting a change of administrator only, submit Form 3722-N, Application for Change — Nursing Facility Administrator or Administrator for Facilities Serving Persons with Mental Retardation or Related Conditions.
  • Enter the effective date of the administrator change.
  • Submit a copy of the required documents as specified in Attachment A: Required Documents by Type of Application.

Real Estate Change — Check this box to supply information about sale of the real estate, change of the real estate owner, change of the recorded deed holder, or amendment or assignment of the leases or subleases.

  • Enter the effective date of the real estate change. During the application review process, DADS may change the effective date to reflect the effective date approved by DADS.
  • Submit a copy of the required documents as specified in Attachment A: Required Documents by Type of Application.

Shares Transfer (49% or less) — Check this box to supply information about a transfer of 49% or less in shares, controlling interest, or managing interest at any level of the organizational structure.

  • Enter the effective date of the transfer. During the application review process, DADS may change the effective date to reflect the effective date approved by DADS.
  • Submit a copy of the required documents as specified in Attachment A: Required Documents by Type of Application.

Management Company — Check this box when the current license holder proposes to contract with a management services provider/company, or when the license holder currently contracts with a management services provider/company and is entering into a new contract with a different management services provider/company. If the application is for an initial license or initial Medicaid certification and the applicant has contracted with, or proposes to contract with, a management services provider/company, check the applicable boxes and follow the instructions for Management Company and Initial.

Note: If the applicant is changing information of a current management services provider/company, check the applicable boxes and follow the instructions for Other Update(s).

Management services provider/company is defined as an individual or legal entity contracted by the applicant to provide management services.

Management services is defined as services provided under contract or other arrangement between the owner of the facility and a person to provide for the operation of a facility, including administration, staffing, maintenance, or delivery of resident services. Management services do not include contracts solely for maintenance, laundry, or food service.

  • Enter the effective date on which the management agreement commences. During the application review process, DADS may change the effective date to reflect the effective date approved by DADS.
  • Submit a copy of the required documents as specified in Attachment A: Required Documents by Type of Application.

Reopen — Check this box when the applicant is reopening a facility for which the license has not expired. If the applicant is reopening a facility whose license has expired, check the applicable boxes and follow the instructions for Reopen and Initial.

  • Submit a copy of the required documents as specified in Attachment A: Required Documents by Type of Application.

Other Update — Check this box to update the most recent information supplied by the applicant to DADS.

Update is defined as a change to information previously supplied by the applicant to DADS. (Example: A change of the real property owner’s address is an update, but a change of the real property owner is a real estate change. A change of a controlling person with no ownership interest is an update, but a change of a controlling person with ownership interest is either a shares transfer or change of ownership, depending on the percentage of ownership interest.)

  • Enter the type of update. Enter an explanation of the information being updated and the corresponding item number (for example, Controlling Persons, Item 7).
  • Enter the effective date of the update. During the application review process, DADS may change the effective date to reflect the effective date approved by DADS.
  • Submit a copy of the required documents as specified in Attachment A: Required Documents by Type of Application.

Bed Changes

Refer to Provider Letter 01-39 — Bed Change Procedures — for instructions and requirements related to Medicaid bed capacity changes.

Medicaid Capacity Change — Check this box to apply for a change in the number of beds certified for participation in the Title 18 Medicaid program.

  • Enter the effective date requested for the Medicare bed capacity change in accordance with procedures specified in Provider Letter 01-39 — Bed Change Procedures. During the application review process, DADS may change the effective date to reflect the effective date approved by DADS.
  • Submit a copy of the required documents as specified in Attachment A: Required Documents by Type of Application.

Medicare Capacity Change — Check this box to apply for a change in the number of beds certified for participation in the Title 19 Medicare program.

  • Enter the effective date requested for the Medicaid bed capacity change in accordance with procedures specified in Provider Letter 01-39 — Bed Change Procedures. During the application review process, DADS may change the effective date to reflect the effective date approved by DADS.
  • Submit a copy of the required documents as specified in Attachment A: Required Documents by Type of Application.

Item 4 — Number of Beds/Application Fee

Enter the number of facility beds for each type listed and provide the total number of facility beds.

Currently Licensed/Certified Beds

Enter the currently licensed/certified number of beds for each category (for example, for applications for initial license, enter 0).

Title 18 Medicare Only — Enter the total number of beds certified for participation in the Title 18 Medicare program only.

Title 18/19 Medicare/Medicaid (dually certified) — Enter the total number of beds certified for participation in both the Title 18 Medicare and Title 19 Medicaid programs (dually certified).

Title 19 Medicaid Only — Enter the total number of beds certified for participation in the Title 19 Medicaid program only.

Licensed Only — Enter the total number of licensed-only beds (beds not certified for participation in Title 18 Medicare and/or Title 19 Medicaid programs).

Total Bed Capacity — Enter the total number of beds currently licensed/certified (this number should be the sum of the previous four fields).

Proposed Licensed/Certified Beds

To request a change to the number of currently licensed/certified beds, check the applicable checkboxes in Item 3: License Capacity Increase or Decrease, Medicare Capacity Change or Medicaid Capacity Change.

Title 18 Medicare Only — Enter the total number of beds requested for participation in the Title 18 Medicare program only.

Title 18/19 Medicare/Medicaid (dually certified) — Enter the total number of beds requested for participation in both the Title 18 Medicare and Title 19 Medicaid programs (dually certified).

Title 19 Medicaid Only — Enter the total number of beds requested for participation in the Title 19 Medicaid program only.

Licensed Only — Enter the total number of licensed-only beds requested (beds not certified for participation in Title 18 Medicare and/or Title 19 Medicaid programs).

Total Bed Capacity — Enter the total number of beds for which licensure/certification is requested.

Note: The proposed Total Bed Capacity must equal the current Total Bed Capacity unless the applicant has checked the License Capacity Increase or Decrease checkbox.

Change in Total Bed Capacity — Enter the difference between the number of beds currently licensed/certified and the number of beds for which the applicant requests licensure/certification (for example: if the licensee's current Total Bed Capacity is 50 beds and the applicant is requesting an additional 5 licensed-only beds, enter 5. If the licensee's current Total Bed Capacity is 50 beds and the applicant wishes to decrease their licensed-only beds by 5, enter -5.).

Total Fee — Enter the fee amount based on the rates specified in the fee schedule below.

Fee Instructions

All applicants pay the rate as indicated for the applicable type of licensure application; fees are not associated with Title 19 Medicaid certification.

Fee Schedule

Initial License $375 + $15 per bed
License Renewal $375 + $15 per bed
Relocation $250 + $15 per bed
Licensed Capacity Increase $15 per bed
Change of Ownership $375 + $15 per bed
Probationary $175 + $ 5 per bed
Change of Administrator $20
Real Estate Change No Fee
Management Company No Fee
Share Transfer No Fee
Reopen No Fee
Other Update No Fee

Note: The fees for initial licensure applications, licensure change of ownership applications, licensure renewal applications and probationary licensure applications include a $50 background check fee.

Initial License — Enter the fee amount based on the applicable category specified below.

  • Two-year license: If the applicant has been licensed previously, or is licensed currently, to operate a nursing facility in Texas, submit the Initial License fee.
  • Three-year license: Initial licenses with an effective date of Sept. 1, 2013, or later will be issued a three-year license.
  • Probationary (one-year license): If the applicant has not previously been licensed to operate a nursing facility in Texas, submit the probationary fee only.

License Renewal — If the applicant is renewing an existing nursing facility license, submit the License Renewal fee. Note: Beginning with licenses expiring Sept. 1, 2013, DADS will issue a three-year license to facilities with a facility identification number ending in an odd digit, and issue a two-year license to facilities with a facility identification number ending in an even digit. The license renewal fee for facilities receiving a two-year license will be two-thirds of the current renewal fee. DADS will provide renewal applicants with a payment coupon containing their required renewal fee. DADS will issue three-year licenses to all facilities beginning Sept. 1, 2014.

Relocation — If the applicant is applying for an initial license due to the relocation of a facility, submit the Relocation fee. Note: Initial licenses with an effective date of Sept. 1, 2013, or later will be issued a three-year license.

License Capacity Increase or Decrease — If the applicant is applying for an increase in the number of licensed beds submit the License Capacity Increase fee. No fee is associated with a license capacity decrease.

Change of Ownership — Enter the fee amount based upon the applicable category specified below.

  • Two-year license: If the applicant has been licensed previously, or is licensed currently, to operate a nursing facility in Texas, submit the Change of Ownership fee.
  • Three-year license: Change of ownership licenses issued with an effective date of Sept. 1, 2013, or later will be issued a three-year license.
  • Probationary (one-year license): If the applicant has not previously been licensed to operate a nursing facility in Texas, submit the Probationary fee only.

Updates

Change of Administrator — If the applicant is reporting a change of administrator with a renewal or change of ownership application.

Real Estate Change — No fee.

Management Company — No fee.

Shares Transfer — No fee.

Reopen — No fee is associated with reopening a facility for which the license has not expired. If the applicant is reopening a facility whose license has expired, use the rate for Initial License.

Other Update(s) — No fee.

Item 5 — Applicant — Legal Entity Information

Legal Name of Applicant (corporation, LLC, partnership, sole proprietorship, etc.) — Enter the legal name of the business or governmental entity applying for the license and/or Title 19 Medicaid certification, as chartered, filed, registered or otherwise legally declared.

Note: For all applications except probationary, initial, and change of ownership, the name of the applicant/legal entity must be identical to the name presently on the license. If it is different, you must apply for a change of ownership or provide legal evidence of a name change for the same business entity.

Taxpayer Identification No. — Enter the nine-digit federal taxpayer identification number of the legal business entity assigned by the Internal Revenue Service (IRS). (Temporary taxpayer identification numbers are not acceptable.)

For an individual who has not been assigned a federal taxpayer identification number by the IRS, the Social Security number (SSN) assigned by the Social Security Administration may be used as the taxpayer identification number. Individuals who do not wish to disclose their SSN must obtain a taxpayer identification number from the IRS before submitting the application.

Fiscal Year End — Enter the fiscal year end date of the applicant.

Physical Address — Street, City, State, ZIP and Country — Self-explanatory.

Mailing Address — Street or P. O. Box, City, State, ZIP and Country — Enter the main office address of the applicant's business entity where all correspondence, etc., (except facility license) will be mailed. Do not enter the facility's address in this box unless the main office address of the applicant's business entity is also the facility's address.

Same as Physical Address — Check this box if the mailing address is the same as the physical address.

Warrant Address, Street or P.O. Box, City, State, ZIP and Country — Enter the address of the legal entity where payments will be mailed.

Same as Physical Address — Check this box if the warrant address is the same as the physical address.

Same as Mailing Address — Check this box if the warrant address is the same as the physical address.

Area Code and Telephone No. — Self-explanatory.

Area Code and Fax No. — Self-explanatory.

Email Address — Self-explanatory. If no email address, leave blank.

Applicant Contact Person Information

Contact Person — Self-explanatory.

Area Code and Telephone No. — Self-explanatory.

Area Code and Fax No. — Self-explanatory.

Email Address — Self-explanatory. If no email address, leave blank.

Title or Relationship to Applicant — Self-explanatory.

Applicant — Legal Entity Type — Check the applicable Applicant Legal Entity Type and submit one copy of each document listed for that type in Attachment B: Required Documents According to Business Entity Type.

Applicant Preparer

Same as Applicant — Check this box if the information is the same as the contact person.

Legal Name of Preparer — Provide information for the contractor or firm that is preparing the application.

Address — Street, City, State, ZIP and Country — Self-explanatory.

Contact Person — Self-explanatory.

Contact Person Title — Self-explanatory.

Area Code and Telephone No. — Self-explanatory.

Area Code and Fax No. — Self-explanatory.

Email Address — Self-explanatory. If no email address, leave blank.

Item 5, Applicant Ownership and Controlling Person Information

The applicant is required to fully disclose all levels of ownership interest in the applicant entity, and is required to disclose all entities and all individuals at each level of ownership, from the ownership of the applicant entity to the ownership of each successive ownership entity.

If additional entries are required for disclosure of all owners and controlling entities/persons, copy this section of Item 5 to use as an attachment for multiple entries. Use a separate page for each business entity disclosed at any level of the ownership structure.

Legal Name of Applicant (corporation, LLC, partnership, sole proprietorship, etc.) — Enter the legal name of the business or governmental entity applying for the license and/or Title 19 Medicaid certification, as chartered, filed, registered, or otherwise legally declared.

Disclose each entity and individual with an ownership interest in the applicant according to the entity type and then disclose each entity and individual who is a controlling entity/person, as specified in Attachment C: Ownership and Controlling Person Information According to Business Entity Type.

Legal Name of Business Entity (if other than individual) — Enter the legal name of the business entity with an ownership interest or other role as a controlling entity in the applicant entity.

Business Entity Type — Enter the applicable type of business entity.

Taxpayer Identification No. — For a business entity, enter the nine-digit federal taxpayer identification number of the legal business entity assigned by the IRS. (Temporary taxpayer identification numbers are not acceptable.)

Last Name (if an individual), First Name, Middle Initial, (Jr., Sr., etc.) — Enter the full name of the individual with an ownership interest or other role as a controlling person in the applicant entity.

Date of Birth — For an individual, enter the person’s date of birth.

Driver License No. (DLN) — For an individual, enter the person’s driver license number.

DLN State of Issue — For an individual, enter the state where the person’s driver license was issued.

Social Security No. — For an individual, record his/her SSN (U.S.) or Social Insurance Number (Canada). DADS requests voluntary disclosure of the SSN in order to conduct the evaluation specified in Texas H&SC §242.032 and Title 40, Chapter 19 of the TAC, §19.201. If the individual chooses not to furnish his or her SSN, the application process may be delayed, and additional information may be requested to validate the individual’s identity.

State/Country of Residence — If the individual being disclosed is a resident of the United States of America, enter the state of the individual’s legal permanent residence. If the individual is not a U.S. resident, enter the country of residence.

% Ownership — Record the percentage of shares, membership shares, etc., owned by the individual/entity being disclosed in this block.

Physical Address — Street, City, State/Province, ZIP/Postal Code, Country — For an individual, enter the physical address of the person’s home. For a business entity, enter the physical address of the business.

Mailing Address — Street or P. O. Box, City, State/Province, ZIP/Postal Code, Country — Enter the mailing address, if different from the physical address.

Title or position held with the entity identified on this page — Enter the title or position this individual/entity holds with the applicant (examples: Shareholder, President, Secretary, Treasurer, Member, Manager, General Partner, Limited Partner, Trustee, etc.).

Start Date of Association (with the entity identified on this page) — Enter the date on which the individual/entity’s association with the entity identified on this page began.

Follow-up questions for all business entity types — Check Yes or No to the questions below.

Has 100% ownership interest been disclosed in this section? — Check Yes or No.
If yes, proceed to the next section.
If no, answer the following questions:

Do each of the remaining individual shareholders own less than 5%? — Check Yes or No.
If yes, proceed to the next section.
If no, disclose all ownership owning 5% or more.

Note: All partnerships must be disclosed fully.

Are the shares publicly traded? — Check Yes or No.
If yes, proceed to the next section.
If no, disclose all ownership owning 5% or more.

Publicly traded is defined as shares of a company that are traded on the open market, such as a stock market.

Are all remaining ownership shares unassigned? — Check Yes or No.
If yes, indicate a statement that the remaining shares are unassigned. Proceed to the next section.
If no, disclose all ownership owning 5% or more.

Are all remaining shares held in treasury of the company? — Check Yes or No.
If yes, indicate a statement that the remaining shares are held in the company's treasury. Proceed to the next section.
If no, disclose all ownership owning 5% or more.

Are all remaining ownership percentage investment funds? — Check Yes or No.
If yes, identify the investment fund. Next to the entity name add the following statement "Investment Fund." Further disclosure is required for investment funds. Proceed to the next section. Identify the investment fund and list the fund advisor or fund manager. Provide proof that the entity is functioning as an investment fund.
If no, disclose all ownership owning 5% or more.

Investment fund is defined as an entity that invests the funds of silent investors. These investors do not have influence or control over the operation of the facility.

Applicant Ownership and Controlling Person Information: Next Level(s)

Based on the first level of ownership information in Item 5, complete the next level(s) of ownership and controlling person information. Complete this section for each business entity previously disclosed in Item 5 and each successive entity.

The applicant is required to fully disclose all levels of ownership interest in the applicant entity, and is required to disclose all entities and all individuals at each level of ownership, from the ownership of the applicant entity to the ownership of each successive ownership entity.

If additional entries are required for disclosure of all owners and controlling entities/person, copy this section of Item 5 to use as an attachment for multiple entries. Use a separate page for each business entity disclosed at any level of the ownership structure.

Legal Name of Business Entity disclosed on this page (corporation, LLC, partnership, sole proprietorship, etc.) — Enter the legal name of the business entity listed in the previous section of Item 5.

Disclose each entity and individual with an ownership interest or other role as a controlling entity in the business entity being disclosed in this section for each level of ownership according to the entity type and then disclose each entity and individual who is a controlling entity/person for each level of ownership as specified in Attachment C: Ownership and Controlling Person Information According to Business Entity Type.

Legal Name of Business Entity (if other than individual) — Enter the legal name of the business entity with an ownership interest or other role as a controlling entity in the business entity being disclosed in this section.

Business Entity Type — Enter the applicable type of business entity.

Taxpayer Identification No. — For a business entity, enter the nine-digit federal taxpayer identification number of the legal business entity assigned by the IRS. (Temporary taxpayer identification numbers are not acceptable.)

Last Name (if an individual), First Name, Middle Initial, (Jr., Sr., etc.) — Enter the full name of the individual with an ownership interest or other role as a controlling person in the business entity being disclosed in this section.

Date of Birth — For an individual, enter the person’s date of birth.

Driver License No. (DLN) — For an individual, enter the person’s driver license number.

DLN State of Issue — For an individual, enter the state where the person’s driver license was issued.

Social Security No. — For an individual, record his/her SSN (U.S.) or Social Insurance Number (Canada). DADS requests voluntary disclosure of the SSN in order to conduct the evaluation specified in Texas H&SC §242.032 and Title 40, Chapter 19 of the TAC, §19.201. If the individual chooses not to furnish his or her SSN, the application process may be delayed, and additional information may be requested to validate the individual’s identity.

State/Country of Residence — If the individual being disclosed is a resident of the United States of America, enter the state of the individual’s legal permanent residence. If the individual is not a U.S. resident, enter the country of residence.

% Ownership — Record the percentage of shares, membership shares, etc., owned by the individual/entity being disclosed in this block.

Physical Address — Street, City, State/Province, ZIP/Postal Code, Country — For an individual, enter the physical address of the person’s home. For a business entity, enter the physical address of the business.

Mailing Address — Street or P. O. Box, City, State/Province, ZIP/Postal Code, Country — Enter the mailing address, if different from the physical address.

Title or Position Held (with the entity identified on this page) — Enter the title or position this individual/entity holds with the entity identified at the top of this page (examples: Shareholder, President, Secretary, Treasurer, Member, Manager, General Partner, Limited Partner, Trustee, etc.).

Start Date of Association (with the entity identified on this page) — Enter the date on which the individual/entity’s association with the entity identified on this page began.

Follow-up questions for all business entity types — Check Yes or No to the questions below.

Has 100% ownership interest been disclosed in this section? — Check Yes or No.
If yes, proceed to the next section.
If no, answer the following questions:

Do each of the remaining individual shareholders own less than 5%? — Check Yes or No.
If yes, proceed to the next section.
If no, disclose all ownership owning 5% or more.

Note: All partnerships must be disclosed fully.

Are the shares publicly traded? — Check Yes or No.
If yes, proceed to the next section.
If no, disclose all ownership owning 5% or more.

Publicly traded is defined as shares of a company that are traded on the open market, such as a stock market.

Are all remaining ownership shares unassigned? — Check Yes or No.
If yes, indicate a statement that the remaining shares are unassigned. Proceed to the next section.
If no, disclose all ownership owning 5% or more.

Are all remaining shares held in treasury of the company? — Check Yes or No.
If yes, indicate a statement that the remaining shares are held in the company's treasury. Proceed to the next section.
If no, disclose all ownership owning 5% or more.

Are all remaining ownership percentage investment funds? — Check Yes or No.
If yes, identify the investment fund. Next to the entity name add the following statement: Investment Fund. Further disclosure is required for investment funds. Proceed to the next section. Identify the investment fund and list the fund advisor or fund manager. Provide proof that the entity is functioning as an investment fund.
If no, disclose all ownership owning 5% or more.

Investment fund is defined as an entity that invests the funds of silent investors. These investors do not have influence or control over the operation of the facility.

Item 6 — Management Company Information

If the facility is operated by, or proposed to be operated by, a management services provider/company (an individual or legal entity contracted by the applicant to provide management services), enter the name, business entity type, tax identification number, address, and contact person for the management company.

Legal Name of Business Entity (if other than individual) — Enter the legal name of the management company, as chartered, filed, registered, or otherwise legally declared.

Business Entity Type — Enter the applicable type of business entity.

Taxpayer Identification No. — Enter the nine digit taxpayer identification number of the legal business entity assigned by the IRS. (Temporary taxpayer identification numbers are not acceptable.) For an individual who has not been assigned a taxpayer identification number by the IRS, the SSN assigned by the Social Security Administration may be used as the taxpayer identification number. Individuals who do not wish to disclose their SSN must obtain a taxpayer identification number from the IRS before submission of the application.

Last Name (if an individual), First Name, Middle Initial, (Jr., Sr., etc.) — Enter the full name of the individual contracted by the applicant to provide management services.

Physical Address — Street, City, State/Province, ZIP/Postal Code, Country — For an individual, enter the physical address of the person’s home. For a business entity, enter the physical address of the business.

Mailing Address (if different from Physical Address) — Street, City, State/Province, ZIP/Postal Code, Country — Enter the mailing address, if different from the physical address.

Area Code and Telephone No. — Self-explanatory.

Area Code and Fax No. — Self-explanatory.

Email Address — Self-explanatory. If no email address, leave blank.

Management Company Contact Person Information

Last Name, First Name, Middle Initial, (Jr., Sr., etc.) — Enter the full name of the person who can be contacted about the information in the application regarding the management company.

Area Code and Telephone No. — Self-explanatory.

Area Code and Fax No. — Self-explanatory.

Email Address — Self-explanatory. If no email address, leave blank.

Title or Relationship to Management Company — Enter the contact person's professional or personal relationship to the management company (examples: Authorized Representative, President, Partner, Manager, Administrator, Administrative Assistant, Spouse, etc.).

Management Company Ownership and Controlling Person Information

The applicant is required to fully disclose all levels of ownership interest in the management company, and is required to disclose all entities and all individuals at each level of ownership, from the ownership of the management company to the ownership of each successive ownership entity.

If additional entries are required for disclosure of all owners and controlling entities/persons, copy this section of Item 6 to use as an attachment for multiple entries. Use a separate page for each business entity disclosed at any level of the ownership structure.

Legal Name of Management Company (corporation, LLC, partnership, sole proprietorship, etc.) — Enter the legal name of the management company, as chartered, filed, registered, or otherwise legally declared.

Disclose each entity and individual with an ownership interest in the management company according to the entity type and then disclose each entity and individual who is a controlling entity/person as specified in Attachment C: Ownership and Controlling Person Information According to Business Entity Type.

Legal Name of Business Entity (if other than individual) — Enter the legal name of the business entity with an ownership interest or other role as a controlling entity in the management company.

Business Entity Type — Enter the applicable type of business entity.

Taxpayer Identification No. — For a business entity, enter the nine-digit taxpayer identification number of the legal business entity assigned by the IRS. (Temporary taxpayer identification numbers are not acceptable.)

Last Name (if an individual), First Name, Middle Initial, (Jr., Sr., etc.) — Enter the full name of the individual with an ownership interest or other role as a controlling person in the management company.

Date of Birth — For an individual, enter the person’s date of birth.

Driver License No. (DLN) — For an individual, enter the person’s driver license number.

DLN State of Issue — For an individual, enter the state where the person’s driver license was issued.

Social Security No. — For an individual, record his/her SSN (U.S.) or Social Insurance Number (Canada). DADS requests voluntary disclosure of the SSN in order to conduct the evaluation specified in Texas H&SC §242.032 and Title 40, Chapter 19 of the TAC, §19.201. If the individual chooses not to furnish his or her SSN, the application process may be delayed, and additional information may be requested to validate the individual’s identity.

State/Country of Residence — If the individual being disclosed is a resident of the United States of America, enter the state of the individual’s legal permanent residence. If the individual is not a U.S. resident, enter the country of residence.

% Ownership — Record the percentage of shares, membership shares, etc., owned by the individual/entity being disclosed in this block.

Physical Address — Street, City, State/Province, ZIP/Postal Code, Country — For an individual, enter the physical address of the person’s home. For a business entity, enter the physical address of the business.

Mailing Address — Street or P.O. Box, City, State/Province, ZIP/Postal Code, Country (if different from Physical Address) — Enter the mailing address, if different from the physical address.

Title or Position Held (with the entity identified on this page) — Enter the title or position this individual/entity holds with the management company (examples: Shareholder, President, Secretary, Treasurer, Member, Manager, General Partner, Limited Partner, Trustee, etc.).

Start Date of Association (with the entity identified on this page) — Enter the date on which the individual/entity’s association with the entity identified on this page began.

Follow-up questions for all business entity types — Check Yes or No to the questions below.

Has 100% ownership interest been disclosed in this section? — Check Yes or No.
If yes, proceed to the next section.
If no, answer the following questions:

Do each of the remaining individual shareholders own less than 5%? — Check Yes or No.
If yes, proceed to the next section.
If no, disclose all ownership owning 5% or more.

Note: All partnerships must be disclosed fully.

Are the shares publicly traded? — Check Yes or No.
If yes, proceed to the next section.
If no, disclose all ownership owning 5% or more.

Publicly traded is defined as shares of a company that are traded on the open market, such as a stock market.

Are all remaining ownership shares unassigned? — Check Yes or No.
If yes, indicate a statement that the remaining shares are unassigned. Proceed to the next section.
If no, disclose all ownership owning 5% or more.

Are all remaining shares held in treasury of the company? — Check Yes or No.
If yes, indicate a statement that the remaining shares are held in the company's treasury. Proceed to the next section.
If no, disclose all ownership owning 5% or more.

Are all remaining ownership percentage investment funds? — Check Yes or No.
If yes, identify the investment fund. Next to the entity name add the following statement: Investment Fund. Further disclosure is required for investment funds. Proceed to the next section. Identify the investment fund and list the fund advisor or fund manager. Provide proof that the entity is functioning as an investment fund.
If no, disclose all ownership owning 5% or more.

Investment fund is defined as an entity that invests the funds of silent investors. These investors do not have influence or control over the operation of the facility.

Management Company Ownership and Controlling Person Information: Next Level(s)

Based on the first level of management company ownership information in Item 6, complete the next level(s) of ownership and controlling person information. Complete this section for each business entity previously disclosed in Item 6 and each successive entity.

The applicant is required to fully disclose all levels of ownership interest in the management company, and is required to disclose all entities and all individuals at each level of ownership, from the ownership of the management company to the ownership of each successive ownership entity.

If additional entries are required for disclosure of all owners and controlling entities/persons, copy this section of Item 6 to use as an attachment for multiple entries. Use a separate page for each business entity disclosed at any level of the ownership structure.

Legal Name of Business Entity disclosed on this page (corporation, LLC, partnership, sole proprietorship, etc.) — Enter the legal name of the business entity listed in the previous section of Item 6.

Disclose each entity and individual with an ownership interest in the management company for each level of ownership according to the entity type and then disclose each entity and individual who is a controlling entity/person for each level of ownership as specified in Attachment C: Ownership and Controlling Person Information According to Business Entity Type.

Legal Name of Business Entity (if other than individual) — Enter the legal name of the business entity with an ownership interest or other role as a controlling entity in the business entity being disclosed in this section.

Business Entity Type — Enter the applicable type of business entity.

Taxpayer Identification No. — For a business entity, enter the nine-digit taxpayer identification number of the legal business entity assigned by the IRS. (Temporary taxpayer identification numbers are not acceptable.)

Last Name (if an individual), First Name, Middle Initial, (Jr., Sr., etc.) — Enter the full name of the individual with an ownership interest or other role as a controlling person in the legal business entity being disclosed in this section.

Date of Birth — For an individual, enter the person’s date of birth.

Driver License No. (DLN) — For an individual, enter the person’s driver license number.

DLN State of Issue — For an individual, enter the state where the person’s driver license was issued.

Social Security No. — For an individual, record his/her SSN (U.S.) or Social Insurance Number (Canada). DADS requests voluntary disclosure of the SSN in order to conduct the evaluation specified in Texas H&SC §242.032 and Title 40, Chapter 19 of the TAC, §19.201. If the individual chooses not to furnish his or her SSN, the application process may be delayed, and additional information may be requested to validate the individual’s identity.

State/Country of Residence — If the individual being disclosed is a resident of the United States of America, enter the state of the individual’s legal permanent residence. If the individual is not a U.S. resident, enter the country of residence.

% Ownership — Record the percentage of shares, membership shares, etc., owned by the individual/entity being disclosed in this block.

Physical Address — Street, City, State/Province, ZIP/Postal Code, Country — For an individual, enter the physical address of the person’s home. For a business entity, enter the physical address of the business.

Mailing Address — Street or P.O. Box, City, State/Province, ZIP/Postal Code, Country (if different from Physical Address) — Enter the mailing address, if different from the physical address.

Title or position held (with the entity identified on this page) — Enter the title or position this individual/entity holds with the entity identified at the top of this page (Examples: Shareholder, President, Secretary, Treasurer, Member, Manager, General Partner, Limited Partner, Trustee, etc.).

Start Date of Association (with the entity identified on this page) — Enter the date on which the individual/entity’s association with the entity identified on this page began.

Follow-up questions for all business entity types — Check Yes or No to the questions below.

Has 100% ownership interest been disclosed in this section? — Check Yes or No.
If yes, proceed to the next section.
If no, answer the following questions:

Do each of the remaining individual shareholders own less than 5%? — Check Yes or No.
If yes, proceed to the next section.
If no, disclose all ownership owning 5% or more.

Note: All partnerships must be disclosed fully.

Are the shares publicly traded? — Check Yes or No.
If yes, proceed to the next section.
If no, disclose all ownership owning 5% or more.

Publicly traded is defined as shares of a company that are traded on the open market, such as a stock market.

Are all remaining ownership shares unassigned? — Check Yes or No.
If yes, indicate a statement that the remaining shares are unassigned. Proceed to the next section.
If no, disclose all ownership owning 5% or more.

Are all remaining shares held in treasury of the company? — Check Yes or No.
If yes, indicate a statement that the remaining shares are held in the company's treasury. Proceed to the next section.
If no, disclose all ownership owning 5% or more.

Are all remaining ownership percentage investment funds? — Check Yes or No.
If yes, identify the investment fund. Next to the entity name add the following statement: Investment Fund. Further disclosure is required for investment funds. Proceed to the next section. Identify the investment fund and list the fund advisor or fund manager. Provide proof that the entity is functioning as an investment fund.
If no, disclose all ownership owning 5% or more.

Investment fund is defined as an entity that invests the funds of silent investors. These investors do not have influence or control over the operation of the facility.

Item 7 — Other Controlling Entity/Person Information

Provide the information requested for any business entity or individual not disclosed in Items 5 and 6 of the application who meets the definition of controlling person, as defined in the General Instructions (for example: A landlord who exerts influence over the disbursement of facility funds or any other aspect of facility operation meets the definition of controlling person.)

If additional entries are required for disclosure of all owners and controlling entities/persons, copy this section of Item 7 to use as an attachment for multiple entries. Use a separate page for each business entity disclosed at any level of the ownership structure.

Legal Name of Business Entity (if other than individual) — Enter the name of the controlling entity.

Business Entity Type — Enter the applicable type of business entity.

Taxpayer Identification No. — For a business entity, enter the nine-digit taxpayer identification number of the legal business entity assigned by the IRS. (Temporary taxpayer identification numbers are not acceptable.)

Last Name (if an individual), First Name, Middle Initial, (Jr., Sr., etc.) — Enter the full name of the individual who is a controlling person.

Date of Birth — For an individual, enter the person’s date of birth.

Driver License No. (DLN) — For an individual, enter the person’s driver license number.

DLN State of Issue — For an individual, enter the state where the person’s driver license was issued.

Social Security No. — For an individual, record his/her SSN (U.S.) or Social Insurance Number (Canada). DADS requests voluntary disclosure of the SSN in order to conduct the evaluation specified in Texas H&SC §242.032 and Title 40, Chapter 19 of the TAC, §19.201. If the individual chooses not to furnish his or her SSN, the application process may be delayed, and additional information may be requested to validate the individual’s identity.

State/Country of Residence — If the individual being disclosed is a resident of the United States of America, enter the state of the individual’s legal permanent residence. If the individual is not a U.S. resident, enter the country of residence.

Physical Address — Street, City, State/Province, ZIP/Postal Code, Country — For an individual, enter the physical address of the person’s home. For a business entity, enter the physical address of the business.

Mailing Address (if different from Physical Address) — Street or P. O. Box, City, State, ZIP — Enter the mailing address, if different from the physical address.

Relationship to Applicant — Enter the individual/business entity’s professional or personal relationship to the applicant (for example: Landlord who exerts influence over the operation of the facility, Professional Consultant or Consulting Company, Spouse, etc.).

Other Controlling Entity/Person Contact Person Information

Last Name, First Name, Middle Initial, (Jr., Sr., etc.) — For a controlling entity, enter the full name of the person who can be contacted for information about the controlling entity. For a controlling person, enter the full name of that person.

Area Code and Telephone No. — Self-explanatory.

Area Code and Fax No. — Self-explanatory.

Email Address — Self-explanatory. If no email address, leave blank.

Title or Relationship to Other Controlling Entity/Person — Enter the contact person's professional or personal relationship to the other controlling entity/person (for example: Authorized Representative, President, Partner, Manager, Administrator, Administrative Assistant, Spouse, etc.).

Other Controlling Entity Ownership and Controlling Person Information

The applicant is required to fully disclose all levels of ownership interest in the other controlling entity, and is required to disclose all entities and all individuals at each level of ownership, from the ownership of the other controlling entity to the ownership of each successive ownership entity.

If additional entries are required for disclosure of all owners and controlling entities/persons, copy this section of Item 7 to use as an attachment for multiple entries. Use a separate page for each business entity disclosed at any level of the ownership structure.

Legal Name of Other Controlling Entity (corporation, LLC, partnership, sole proprietorship, etc.) — Enter the legal name of the business entity that meets the definition of controlling person.

Disclose each entity and individual with an ownership interest in the other controlling entity according to the entity type and then disclose each entity and individual who is a controlling entity/person as specified in Attachment C: Ownership and Controlling Person Information According to Business Entity Type.

Legal Name of Business Entity (if other than individual) — Enter the legal name of the business entity with an ownership interest or other role as a controlling entity in the other controlling entity being disclosed in this section.

Business Entity Type — Enter the applicable type of business entity.

Taxpayer Identification No. — For a business entity, enter the nine-digit taxpayer identification number of the legal business entity assigned by the IRS. (Temporary taxpayer identification numbers are not acceptable.)

Last Name (if an individual), First Name, Middle Initial, (Jr., Sr., etc.) — Enter the full name of the individual with an ownership interest or other role as a controlling person in the controlling entity being disclosed in this section.

Date of Birth — For an individual, enter the person’s date of birth.

Driver License No. (DLN) — For an individual, enter the person’s driver license number.

DLN State of Issue — For an individual, enter the state where the person’s driver license was issued.

Social Security No. — For an individual, record his/her SSN (U.S.) or Social Insurance Number (Canada). DADS requests voluntary disclosure of the SSN in order to conduct the evaluation specified in Texas H&SC §242.032 and Title 40, Chapter 19 of the TAC, §19.201. If the individual chooses not to furnish his or her SSN, the application process may be delayed, and additional information may be requested to validate the individual’s identity.

State/Country of Residence — If the individual being disclosed is a resident of the United States of America, enter the state of the individual’s legal permanent residence. If the individual is not a U.S. resident, enter the country of residence.

% Ownership — Record the percentage of shares, membership shares, etc., owned by the individual/entity being disclosed in this block.

Physical Address — Street, City, State/Province, ZIP/Postal Code, Country — For an individual, enter the physical address of the person’s home. For a business entity, enter the physical address of the business.

Mailing Address — Street or P.O. Box, City, State/Province, ZIP/Postal Code, Country (if different from Physical Address) — Enter the mailing address, if different from the physical address.

Title or Position Held (with the entity identified on this page) — Enter the title or position this individual/entity holds with the other controlling entity (for example, Shareholder, President, Secretary, Treasurer, Member, Manager, General Partner, Limited Partner, Trustee, etc.).

Start Date of Association (with the entity identified on this page) — Enter the date on which the individual/entity’s association with the entity identified on this page began.

Follow-up questions for all business entity types — Check Yes or No to the questions below.

Has 100% ownership interest been disclosed in this section? — Check Yes or No.
If yes, proceed to the next section.
If no, answer the following questions:

Do each of the remaining individual shareholders own less than 5%? — Check Yes or No.
If yes, proceed to the next section.
If no, disclose all ownership owning 5% or more.

Note: All partnerships must be disclosed fully.

Are the shares publicly traded? — Check Yes or No.
If yes, proceed to the next section.
If no, disclose all ownership owning 5% or more.

Publicly traded is defined as shares of a company that are traded on the open market, such as a stock market.

Are all remaining ownership shares unassigned? — Check Yes or No.
If yes, indicate a statement that the remaining shares are unassigned. Proceed to the next section.
If no, disclose all ownership owning 5% or more.

Are all remaining shares held in treasury of the company? — Check Yes or No.
If yes, indicate a statement that the remaining shares are held in the company's treasury. Proceed to the next section.
If no, disclose all ownership owning 5% or more.

Are all remaining ownership percentage investment funds? — Check Yes or No.
If yes, identify the investment fund. Next to the entity name add the following statement: Investment Fund. Further disclosure is required for investment funds. Proceed to the next section. Identify the investment fund and list the fund advisor or fund manager. Provide proof that the entity is functioning as an investment fund.
If no, disclose all ownership owning 5% or more.

Investment fund is defined as an entity that invests the funds of silent investors. These investors do not have influence or control over the operation of the facility.

Other Controlling Entity Ownership and Controlling Person Information: Next Level(s)

Based on the first level of ownership information in Item 7, complete the next level(s) of ownership and controlling person information. Complete this section for each business entity previously disclosed in Item 7 and each successive entity.

The applicant is required to fully disclose all levels of ownership interest in the other controlling entity, and is required to disclose all entities and all individuals at each level of ownership, from the ownership of the other controlling entity to the ownership of each successive ownership entity.

If additional entries are required for disclosure of all owners and controlling entities/persons, copy this section of Item 7 to use as an attachment for multiple entries. Use a separate page for each business entity disclosed at any level of the ownership structure.

Legal Name of Business Entity disclosed on this page (corporation, LLC, partnership, sole proprietorship, etc.) — Enter the legal name of the business entity listed in the previous section of Item 7.

Disclose each entity and individual with an ownership interest in the other controlling entity for each level of ownership according to the entity type and then disclose each entity and individual who is a controlling entity/person for each level of ownership as specified in Attachment C: Ownership and Controlling Person Information According to Business Entity Type.

Legal Name of Business Entity (if other than individual) — Enter the legal name of the business entity with an ownership interest or other role as a controlling entity in the business entity being disclosed in this section.

Business Entity Type — Enter the applicable type of business entity.

Taxpayer Identification No. — For a business entity, enter the nine-digit taxpayer identification number of the legal business entity assigned by the IRS. (Temporary taxpayer identification numbers are not acceptable.)

Last Name (if an individual), First Name, Middle Initial, (Jr., Sr., etc.) — Enter the full name of the individual with an ownership interest or other role as a controlling person in the business entity being disclosed in this section.

Date of Birth — For an individual, enter the person’s date of birth.

Driver License No. (DLN) — For an individual, enter the person’s driver license number.

DLN State of Issue — For an individual, enter the state where the person’s driver license was issued.

Social Security No. — For an individual, record his/her SSN (U.S.) or Social Insurance Number (Canada). DADS requests voluntary disclosure of the SSN in order to conduct the evaluation specified in Texas H&SC §242.032 and Title 40, Chapter 19 of the TAC, §19.201. If the individual chooses not to furnish his or her SSN, the application process may be delayed, and additional information may be requested to validate the individual’s identity.

State/Country of Residence — If the individual being disclosed is a resident of the United States of America, enter the state of the individual’s legal permanent residence. If the individual is not a U.S. resident, enter the country of residence.

% Ownership — Record the percentage of shares, membership shares, etc., owned by the individual/entity being disclosed in this block.

Physical Address — Street, City, State/Province, ZIP/Postal Code, Country — For an individual, enter the physical address of the person’s home. For a business entity, enter the physical address of the business.

Mailing Address — Street or P.O. Box, City, State/Province, ZIP/Postal Code, Country (if different from Physical Address) — Enter the mailing address, if different from the physical address.

Title or Position Held (with the entity identified on this page) — Enter the title or position this individual/entity holds with the entity identified at the top of this page (for examples, Shareholder, President, Secretary, Treasurer, Member, Manager, General Partner, Limited Partner, Trustee, etc.).

Start Date of Association (with the entity identified on this page) — Enter the date on which the individual/entity’s association with the entity identified on this page began.

Follow-up questions for all business entity types — Check Yes or No to the questions below.

Has 100% ownership interest been disclosed in this section? — Check Yes or No.
If yes, proceed to the next section.
If no, answer the following questions:

Do each of the remaining individual shareholders own less than 5%? — Check Yes or No.
If yes, proceed to the next section.
If no, disclose all ownership owning 5% or more.

Note: All partnerships must be disclosed fully.

Are the shares publicly traded? — Check Yes or No.
If yes, proceed to the next section.
If no, disclose all ownership owning 5% or more.

Publicly traded is defined as shares of a company that are traded on the open market, such as a stock market.

Are all remaining ownership shares unassigned? — Check Yes or No.
If yes, indicate a statement that the remaining shares are unassigned. Proceed to the next section.
If no, disclose all ownership owning 5% or more.

Are all remaining shares held in treasury of the company? — Check Yes or No.
If yes, indicate a statement that the remaining shares are held in the company's treasury. Proceed to the next section.
If no, disclose all ownership owning 5% or more.

Are all remaining ownership percentage investment funds? — Check Yes or No.
If yes, identify the investment fund. Next to the entity name add the following statement: Investment Fund. Further disclosure is required for investment funds. Proceed to the next section. Identify the investment fund and list the fund advisor or fund manager. Provide proof that the entity is functioning as an investment fund.
If no, disclose all ownership owning 5% or more.

Investment fund is defined as an entity that invests the funds of silent investors. These investors do not have influence or control over the operation of the facility.

Item 8 — Real Estate Information

Check the appropriate boxes, fill in each applicable blank, and submit a copy of required documents. Disclose all lease agreements, sublease agreements, assignment agreements, and/or any other entitlement to occupy the real property.

If additional entries are required for full disclosure, copy Item 8 of the application to use as an attachment for multiple entries.

Real property is defined as the land on which the facility is located and other properties permanently attached to the land, such as buildings in which the facility is housed.

Note: Submit a copy of each property document which entitles occupation of the real property, such as the deed, lease agreement, lien agreement, sublease agreement, assignment of the lease, court order, etc.

Lien is defined as any official claim or charge against property or funds for payment of a debt or an amount owed for services rendered (for example, a mortgage, a deed of trust, etc.).

A. 1. — Indicate ownership of the real property by checking the applicable box. If the real property is owned solely by the entity identified as the applicant in Item 5, check Yes. If the real property is owned partially by the entity identified as the applicant in Item 5, or by an individual or entity other than the applicant, check No.

To own the real property, as that term is used in Item 8, Section A., means the applicant holds legal title to the real property, as evidenced by deed or other legal, recognizable conveyance, properly filed and recorded in the real property records of the county in which the real property is situated.

If Yes, answer questions A.2. and A.3., and complete Section B. For an initial license application, change of ownership application, or update application for a real estate change, submit a copy of the property ownership document(s) (deed, deeds of trust, special warranty deed, etc.). If No, complete Sections B through O. For an initial license application, change of ownership application, or update application for a real estate change, submit a copy of the property ownership document(s) (deed, deeds of trust, special warranty deed, etc.).

A. 2. — Check Yes or No to indicate whether or not the real property is encumbered by any liens or whether other interest is secured by the real property, such as deeds of trust, tax liens, mechanics liens, judgments, etc.

If Yes, describe the nature of the lien or judgment.

A. 3. — Check Yes or No to indicate whether the applicant is currently in default on any obligation secured or potentially secured by the real property.

If Yes, describe the nature of the default.

B. 1. Legal Name of Business Entity or Individual that owns the real property — Enter the legal name of the business entity(ies) or individual(s) that owns the real property.

Mailing Address — Street or P. O. Box, City, State/Province, ZIP/Postal Code, Country — Enter the entity’s or individual’s (real property owner’s) full mailing address.

B. 2. Real Property Owner Contact Person — Enter the name of the real property owner’s representative who can be contacted about the real estate information in this item.

Last Name, First Name, Middle Initial, (Jr., Sr., etc.) — Enter the full name of the real property owner’s representative.

Area Code and Telephone No. — Self-explanatory.

Area Code and Fax No. — Self-explanatory.

Email Address — Self-explanatory. If no email address, leave blank.

C. — Check Yes or No to indicate whether or not the applicant leases the property from a property owner.

If Yes, submit a copy of the lease agreement for an initial license application, change of ownership application, or update application for a real estate change, or renewal application with a real estate change and stop here. You do not need to complete sections D through O of Item 8.

If No, identify in Section D the business entity(ies) or individual(s) that leases from the real property owner, or identify in Section K the applicant’s entitlement to occupy the real property.

D. Legal Name of Business Entity or Individual that leases from the real property owner — Enter the legal name of the business entity or individual that leases the real property.

Mailing Address — Street or P. O. Box, City, State/Province, ZIP/Postal Code, Country — Enter the entity’s or individual’s full mailing address.

E. — Check Yes or No to indicate whether or not the applicant subleases the property from a business entity(ies) or individual(s) identified in Section D.

If Yes, submit a copy of the primary lease agreement and all sublease agreements for an initial license application, change of ownership application, or update application for a real estate change, or renewal application with a real estate change and stop here. You do not need to complete sections F through O of Item 8.

If No, identify in Section F the business entity(ies) or individual(s) that subleases from the business entity(ies) or individual(s) identified in Section D, or identify in Section K the applicant’s entitlement to the real property.

F. Legal Name of Business Entity or Individual that subleases from the business or individual identified in Section D — Enter the legal name of the business entity or individual that subleases the real property.

Mailing Address — Street or P. O. Box, City, State/Province, ZIP/Postal Code, Country — Enter the entity’s or individual’s full mailing address.

G. — Check Yes or No to indicate whether or not the applicant subleases the property from a business entity or individual identified in Section F.

If Yes, submit a copy of the primary lease agreement and all sublease agreements for an initial license application, change of ownership application, or update application for a real estate change, or renewal application with a real estate change and stop here. You do not need to complete sections H through O of Item 8.

If No, identify in Section H the business entity or individual that subleases from the business entity(ies) or individual(s) identified in Section F, or identify in Section K the applicant’s entitlement to occupy the real property.

H. Legal Name of Business Entity or Individual that subleases the property from the business or individual identified in Section F — Enter the legal name of the business entity or individual that subleases the real property.

Mailing Address — Street or P. O. Box, City, State/Province, ZIP/Postal Code, Country — Enter the entity’s or individual’s full mailing address.

I. — Check Yes or No to indicate whether or not the applicant subleases the property from the business entity or individual identified in Section H.

If Yes, submit a copy of the primary lease agreement and all sublease agreement(s) for an initial license application, change of ownership application, or update application for a real estate change, or renewal application with a real estate change and stop here. You do not need to complete sections J through O of Item 8.

If No, identify in Section J the business entity(ies) or individual(s) that subleases from the business entity or individual identified in Section H, or identify in Section K the applicant’s entitlement to occupy the real property.

J. Legal Name of Business Entity or Individual that subleases the property from a business entity(entities) or individual(s) identified in Section H — Enter the legal name of the business entity or individual that subleases the real property.

Mailing Address — Street or P. O. Box, City, State/Province, ZIP/Postal Code, Country — Enter the entity’s or individual’s full mailing address.

K. — If the applicant does not lease or sublease the property from a business entity(ies) or individual(s) identified in Section D, F, H, or J, enter the type of property document that entitles the applicant to occupy the real property. Submit a copy of the property document that entitles the applicant to occupy the real property.

L. — Check Yes or No to indicate whether or not the applicant holds assignment of the lease or other entitlement to occupy the real property from a business entity(ies) or individual(s) identified in Section D, F, H or J.

If Yes, submit a copy of the assignment agreement or other entitlement to occupy the real property for an initial license application, change of ownership application, or update application for a real estate change, or renewal application with a real estate change and stop here. You do not need to complete sections M through O of Item 8.

If No, identify in Section M the business entity(ies) or individual(s) that holds assignment of the lease or other entitlement to occupy the real property from the business entity(ies) or individual(s) identified in Section D, F, H or J.

M. Legal Name of Business Entity or Individual that holds assignment of the lease or other entitlement to occupy the real property from the business or individual identified in Section D, F, H or J — Enter the legal name of the business entity or individual that holds assignment of the lease or other entitlement to occupy the real property from the business or individual identified in Section D, F, H or J.

Mailing Address — Street or P. O. Box, City, State/Province, ZIP/Postal Code, Country — Enter the entity’s or individual’s full mailing address.

N. — Check Yes or No to indicate whether or not the applicant holds assignment of the lease or other entitlement to occupy the real property from a business entity(ies) or individual(s) identified in Section M.

If Yes, submit a copy of the assignment agreement(s) or other entitlement to occupy the real property for an initial license application, change of ownership application, or update application for a real estate change, or renewal application with a real estate change and stop here. You do not need to complete Section O of Item 8.

If No, identify in Section O the business entity(ies) or individual(s) that holds assignment of the lease or other entitlement to occupy the real property from the business entity(ies) or individual(s) identified in Section M.

O. Legal Name of Business Entity or Individual that holds assignment(s) of the lease or other entitlement to occupy the real property from a business entity(ies) or individual(s) identified in section M — Enter the legal name of the business entity or individual that holds assignment(s) of the lease or other entitlement to occupy the real property from a business entity(ies) or individual(s) identified in section M.

Mailing Address — Street or P. O. Box, City, State/Province, ZIP/Postal Code, Country — Enter entity’s or individual’s full mailing address.

Item 9 — Disclosure of Facility/Agency Association

List all long-term care facilities/agencies that are not licensed by DADS or are located outside of Texas for which an individual/entity listed in Item 5, 6 or 7 is, or was, a controlling person (has the ability, acting alone or in concert with others, to directly or indirectly influence, direct, or cause the direction of the management, expenditure of money, or policies of an institution or other person, as previously defined).

Include facilities/agencies located in Texas and any other state. If the individual(s)/entity(ies) listed in Item 5, 6 or 7 are associated with no facility(ies)/agency(ies), other than the facility in item one, no further entries are required. Provide the requested information for the five-year period up to and including the date of the application.

Long-term care facility/agency includes adult day care facilities, assisted living facilities, durable medical equipment companies, home health agencies, hospices, facilities serving persons with mental retardation or a related condition, and nursing facilities.

Date of the application is defined as the date the applicant or the applicant’s authorized representative signs the Affidavit for Application, Item 14.

If additional entries are required for full disclosure, copy Item 9 of the application to use as an attachment for multiple entries.

Facility/Agency Name — Enter the name of the long-term care facility/agency associated with the above individual(s)/entity(ies) listed in Item 5, 6 or 7; enter the name exactly as it appears on the filed Certificate of Assumed Business Name.

Facility/Agency Identification No. — For facilities/agencies located in Texas, enter the facility/agency identification number issued by the State of Texas; if this number has not yet been issued by the state, enter the facility/agency’s license number. For out-of-state facilities/agencies, enter the identification number issued by the applicable regulatory authority.

National Provider Identifier No. — Enter the National Provider Identifier number (NPI) assigned by the Centers for Medicare & Medicaid Services (CMS) and/or by the state survey agency, if applicable.

Physical Address — Street, City, State, ZIP — Enter the address where the facility/agency is physically located.

Individual/Entity — Enter the names of the individual(s) or business entity(ies) listed in Item 5, 6 or 7 who is, or was, a controlling person of the long-term care facility/agency.

Start Date of Association — Enter the date on which the individual/entity’s association with the facility/agency began.

End Date of Association — Enter the date on which the individual/entity’s association with the facility/agency ended. If the association is ongoing, leave this field blank.

General Disclosure Questions

Complete this section for all individuals and entities listed on the application in Items 5, 6 or 7. General Disclosure Questions A through D have no time-frame limitations. If answering any question affirmatively in relation to a long-term care facility or agency, provide the requested information for the time period during which the individual or entity is or was a controlling person, as indicated in Item 9, Disclosure of Facility/Agency Association.

Respond by checking Yes or No for each section, A through D. If Yes is answered for any question

  • Identify the long-term care facility or agency;
  • Provide the incident details as specified below (if applicable) for each question; and
  • List all individuals/entities who were associated with the facility or agency during the time period in question, as indicated in Item 9, Disclosure of Facility/Agency Association.

If additional entries are required for full disclosure, copy the page to use as an attachment.

A.

Individual/Entity — Enter the name of the individual or entity for which this question is answered affirmatively, and check the appropriate box to indicate the item in which this individual or entity has been identified. You may check multiple boxes, if applicable.

Date of conviction — Enter the date on which the individual/entity was found guilty of the crime.

Conviction — Enter the crime of which the individual/entity was convicted, such as assault, armed robbery, driving under the influence, possession of a controlled substance, etc.

Terms of sentence — Enter the terms of punishment given the individual/entity convicted of the crime, as ordered by the judge, such as jail or prison time, fines, community service, restitution, or other punishment, or terms of probation.

B.

Individual/Entity — Enter the name of the individual or entity for which this question is answered affirmatively, and check the appropriate box to indicate the item in which this individual or entity has been identified. You may check multiple boxes, if applicable.

Date of exclusion or debarment — Enter the date on which the regulatory authority established or applied the exclusion or debarment.

Reason — Enter the reason for the exclusion or debarment, such as Medicaid fraud, conviction of injury to a person who is elderly, etc.

Start Date and End Date — Enter the date range (beginning and end dates) of the exclusion or debarment.

C.

Individual/Entity — Enter the name of the individual or entity for which this question is answered affirmatively, and check the appropriate box to indicate the item in which this individual or entity has been identified. You may check multiple boxes, if applicable.

Date of exclusion or disqualification — Enter the date on which the regulatory authority established or applied the exclusion or disqualification.

Reason — Enter the reason for the exclusion or disqualification, such as use of emergency assistance funds in a facility for which a trustee is appointed for purposes other than to pay the expenses of the trustee, substantial failure to comply with Chapter 242 of the Texas H&SC and Title 40, Chapter 19 of the TAC, Medicaid fraud, conviction of injury to a person who is elderly, etc.

Start Date and End Date — Enter the date range (beginning and end dates) of the exclusion or disqualification.

D.

Individual/Entity — Enter the name of the individual or entity for which this question is answered affirmatively, and check the appropriate box to indicate the item in which this individual or entity has been identified. You may check multiple boxes, if applicable.

Order issued against — Enter the name of the facility/agency or individual/entity against which the court order was issued.

Nature/type of court order — Enter the nature/type of the court order, for example, temporary restraining order, temporary injunction, permanent injunction, etc.

Court issuing order — Enter the name of the court that issued the order, including the county and state.

Terms of court order — Enter the terms specified in the court order, such as the beginning and ending dates for which a restraining order was in effect.

Date order issued — Enter the date on which the court issued the order.

Current status — Enter the current status of the court order, such as order presently in effect or order no longer in effect.

Five-Year Disclosure Questions

Complete this section for all individuals and entities listed on the application in Items 5, 6 or 7. For Five-Year Disclosure Questions E through P, provide the information for the five-year period up to and including the date of the application. The applicant is required to fully disclose all instances for which the answer to a question is affirmative, including all long-term care facilities/agencies as well as all individuals/entities associated with each incident.

Respond by checking Yes or No for each section, E through P. If Yes is answered for any questions:

  • Identify the long-term care facility or agency;
  • Provide the incident details as specified below for each question; and
  • List all individuals/entities who were associated with the facility or agency during the time period in question, as indicated in Item 9, Disclosure of Facility/Agency Association.

If additional entries are required for full disclosure, copy the page to use as an attachment.

E.

Individual/Entity — Enter the name of the individual or entity for which this question is answered affirmatively, and check the appropriate box to indicate the item in which this individual or entity has been identified. You may check multiple boxes, if applicable.

Facility/Agency Name (if applicable) — Enter the name of the long-term care facility/agency for which this question is answered affirmatively; enter the name exactly as it appears on the filed Certificate of Assumed Business Name.

Facility/Agency Identification No. — For facilities/agencies located in Texas, enter the facility/agency identification number issued by the State of Texas; if this number has not yet been issued by the state, enter the facility/agency’s license number. For out-of-state facilities/agencies, enter the identification number issued by the applicable regulatory authority.

National Provider Identifier No. — Enter the federal provider number assigned by CMS and/or the state survey agency, if applicable.

Name of Plaintiff/Complainant — Enter the name of the party who initiated suit.

Nature of Allegations — Enter a brief description of the allegation (statement of claimed fact).

Outcome: Verdict — Enter the decision of the jury, if applicable.

Outcome: Verdict Date — Enter the date of the verdict, if applicable.

Outcome: Verdict Amount — Enter the amount of the verdict, if applicable.

Outcome: Judgment — Enter the final decision of the court, if applicable.

Outcome: Judgment Date — Enter the date of the court’s decision, if applicable.

Outcome: Judgment Amount — Enter the amount that the facility/agency or individual/entity owes(ed) pursuant to the judgment, if applicable.

Outcome: Settlement — Enter the resolution of the lawsuit, if applicable.

Outcome: Settlement Date — Enter the date of the resolution, if applicable.

Outcome: Settlement Amount — Enter the amount of the settlement that resolved the lawsuit, if applicable.

Status — Check the applicable box to indicate whether or not the facility/agency or individual/entity issued complete payment to satisfy the court’s final decision, or issued complete payment to comply with the terms of a settlement.

If the facility/agency or individual/entity did not pay the judgment or settlement, explain the reason for nonpayment.

F.

Individual/Entity — Enter the name of the individual or entity for which this question is answered affirmatively, and check the appropriate box to indicate the item in which this individual or entity has been identified. You may check multiple boxes, if applicable.

Facility/Agency Name (if applicable) — Enter the name of the long-term care facility/agency for which this question is answered affirmatively; enter the name exactly as it appears on the filed Certificate of Assumed Business Name.

Facility/Agency Identification No. — For facilities/agencies located in Texas, enter the facility/agency identification number issued by the State of Texas; if this number has not yet been issued by the state, enter the facility/agency’s license number. For out-of-state facilities/agencies, enter the identification number issued by the applicable regulatory authority.

National Provider Identifier No. — Enter the federal provider number assigned by CMS and/or the state survey agency, if applicable.

Name and Type of Business (if applicable) — Enter the name and type of business (if different from the Facility/Agency name above) for which this question is answered affirmatively; enter the name exactly as it appears on the filed Certificate of Assumed Business Name.

Type of Filing — Check the applicable box to indicate whether the reorganization, bankruptcy, or receivership was a Chapter 7, Chapter 9, Chapter 11, Chapter 13 filing or Receiver.

Date Filed — Enter the date on which the facility/agency or individual/entity filed for reorganization, bankruptcy, or receivership, or, in the event of an involuntary filing, enter the date on which the court entered the order for relief.

Status — Check the applicable box to indicate whether the status of the reorganization, bankruptcy, or receivership is in progress or was discharged, dismissed or confirmed.

G.

Individual/Entity — Enter the name of the individual or entity for which this question is answered affirmatively, and check the appropriate box to indicate the item in which this individual or entity has been identified. You may check multiple boxes, if applicable.

Facility/Agency Name (if applicable) — Enter the name of the long-term care facility/agency for which this question is answered affirmatively; enter the name exactly as it appears on the filed Certificate of Assumed Business Name.

Facility/Agency Identification No. — For facilities/agencies located in Texas, enter the facility/agency identification number issued by the State of Texas; if this number has not yet been issued by the state, enter the facility/agency’s license number. For out-of-state facilities/agencies, enter the identification number issued by the applicable regulatory authority.

National Provider Identifier No. — Enter the federal provider number assigned by CMS and/or the state survey agency, if applicable.

Amount Owed — Enter the amount of the taxes or payment owed.

Name of individual/entity owed — Enter the name of the person or entity to whom the tax or payment is/was owed. Check the applicable box to indicate whether the delinquent taxes or payment have been paid. If they have not been paid, explain the reason for nonpayment.

H.

Individual/EntityEnter the name of the individual or entity for which this question is answered affirmatively, and check the appropriate box to indicate the item in which this individual or entity has been identified. You may check multiple boxes, if applicable.

Facility/Agency Name (if applicable) — Enter the name of the long-term care facility/agency for which this question is answered affirmatively; enter the name exactly as it appears on the filed Certificate of Assumed Business Name.

Facility/Agency Identification No. — For facilities/agencies located in Texas, enter the facility/agency identification number issued by the State of Texas; if this number has not yet been issued by the state, enter the facility/agency’s license number. For out-of-state facilities/agencies, enter the identification number issued by the applicable regulatory authority.

National Provider Identifier No. — Enter the federal provider number assigned by CMS and/or the state survey agency, if applicable.

Basis for fine or penalty — Enter the basis for assignation of the fine or penalty (Example: unpaid payroll taxes).

Date Penalty Imposed — Enter the date the fine or penalty was imposed.

Amount Owed — Enter the amount of the fine or penalty owed.

Name of individual/entity owed — Enter the name of the person or entity to whom the fine or penalty is/was owed.

Status — Check the applicable box to indicate whether the fine or penalty has been paid. If the fine or penalty has not been paid, explain the reason for nonpayment.

I.

Individual/Entity — Enter the name of the individual or entity for which this question is answered affirmatively, and check the appropriate box to indicate the item in which this individual or entity has been identified. You may check multiple boxes, if applicable.

Facility/Agency Name (if applicable) — Enter the name of the long-term care facility/agency for which this question is answered affirmatively; enter the name exactly as it appears on the filed Certificate of Assumed Business Name.

Facility/Agency Identification No. — Enter the facility/agency identification number issued by the State of Texas; if this number has not yet been issued by the state, enter the facility/agency’s license number.

National Provider Identifier No. — Enter the federal provider number assigned by CMS and/or the state survey agency, if applicable.

Type of fee not paid — Enter the type of fee not paid by the facility/agency.

Amount owed — Enter the amount of the fee owed.

Due Date — Enter the date on which the fee was due.

J.

Individual/Entity — Enter the name of the individual or entity for which this question is answered affirmatively, and check the appropriate box to indicate the item in which this individual or entity has been identified. You may check multiple boxes, if applicable.

Facility/Agency Name (if applicable) — Enter the name of the long-term care facility/agency for which this question is answered affirmatively; enter the name exactly as it appears on the filed Certificate of Assumed Business Name.

Facility/Agency Identification No. — Enter the facility/agency identification number issued by the State of Texas; if this number has not yet been issued by the state, enter the facility/agency’s license number.

National Provider Identifier No. — Enter the federal provider number assigned by CMS and/or the state survey agency, if applicable.

Date trustee placed in the facility — Enter the date the trustee assumed operation of the facility as specified by the court order.

Date trustee removed — Enter the date the trusteeship ended. If the trusteeship has not ended, leave this date field blank.

Amount of emergency funds not reimbursed — Enter the amount of funds that were not reimbursed to the Nursing and Convalescent Home Trust Fund in nearest whole dollars.

K.

Individual/Entity — Enter the name of the individual or entity for which this question is answered affirmatively, and check the appropriate box to indicate the item in which this individual or entity has been identified. You may check multiple boxes, if applicable.

Facility/Agency Name (if applicable) — Enter the name of the long-term care facility/agency for which this question is answered affirmatively; enter the name exactly as it appears on the filed Certificate of Assumed Business Name.

Facility/Agency Identification No. — For facilities/agencies located in Texas, enter the facility/agency identification number issued by the State of Texas; if this number has not yet been issued by the state, enter the facility/agency’s license number. For out-of-state facilities/agencies, enter the identification number issued by the applicable regulatory authority.

National Provider Identifier No. — Enter the federal provider number assigned by CMS and/or the state survey agency, if applicable.

Amount of Judgment or Settlement — Enter the amount that the facility/agency or individual/entity owes(ed) pursuant to the judgment or settlement.

Name of Creditor or Claimant — Enter the name of the person or entity to whom the debt is/was owed.

Date of Judgment or Settlement — Enter the date on which judgment was rendered or on which the individual/entity entered into the settlement agreement.

Nature of the default or dispute — Enter the basis for the financial default or dispute that resulted in the judgment or settlement (for example, slip and fall, employment issues, payroll dispute, etc.).

Amount Unpaid — Enter the amount unpaid.

L.

Individual/Entity — Enter the name of the individual or entity for which this question is answered affirmatively, and check the appropriate box to indicate the item in which this individual or entity has been identified. You may check multiple boxes, if applicable.

Facility/Agency Name (if applicable) — Enter the name of the long-term care facility/agency for which this question is answered affirmatively; enter the name exactly as it appears on the filed Certificate of Assumed Business Name.

Facility/Agency Identification No. — For facilities/agencies located in Texas, enter the facility/agency identification number issued by the State of Texas; if this number has not yet been issued by the state, enter the facility/agency’s license number. For out-of-state facilities/agencies, enter the identification number issued by the applicable regulatory authority.

National Provider Identifier No. — Enter the federal provider number assigned by CMS and/or the state survey agency, if applicable.

Date of Eviction — Enter the date on which the facility or agency was evicted.

M.

Individual/Entity — Enter the name of the individual or entity for which this question is answered affirmatively, and check the appropriate box to indicate the item in which this individual or entity has been identified. You may check multiple boxes, if applicable.

Facility/Agency Name (if applicable) — Enter the name of the long-term care facility/agency for which this question is answered affirmatively; enter the name exactly as it appears on the filed Certificate of Assumed Business Name.

Facility/Agency Identification No. — For facilities/agencies located in Texas, enter the facility/agency identification number issued by the State of Texas; if this number has not yet been issued by the state, enter the facility/agency’s license number. For out-of-state facilities/agencies, enter the identification number issued by the applicable regulatory authority.

National Provider Identifier No. — Enter the federal provider number assigned by CMS and/or the state survey agency, if applicable.

Type of Action — Check the applicable box to indicate whether the action against the license was denial, revocation, or suspension.

Effective Date — Enter the effective date of the license denial, revocation, or suspension.

N.

Individual/Entity — Enter the name of the individual or entity for which this question is answered affirmatively, and check the appropriate box to indicate the item in which this individual or entity has been identified. You may check multiple boxes, if applicable.

Facility/Agency Name (if applicable) — Enter the name of the long-term care facility/agency for which this question is answered affirmatively; enter the name exactly as it appears on the filed Certificate of Assumed Business Name.

Facility/Agency Identification No. — For facilities/agencies located in Texas, enter the facility/agency identification number issued by the State of Texas; if this number has not yet been issued by the state, enter the facility/agency’s license number. For out-of-state facilities/agencies, enter the identification number issued by the applicable regulatory authority.

National Provider Identifier No. — Enter the federal provider number assigned by CMS and/or the state survey agency, if applicable.

Date trustee/manager placed in the facility — Enter the date the trustee/manager assumed operation of the facility as specified by the court order.

Date trustee/manager removed — Enter the date the trusteeship/management ended.

O.

Individual/Entity — Enter the name of the individual or entity for which this question is answered affirmatively, and check the appropriate box to indicate the item in which this individual or entity has been identified. You may check multiple boxes, if applicable.

Facility/Agency Name (if applicable) — Enter the name of the long-term care facility/agency for which this question is answered affirmatively; enter the name exactly as it appears on the filed Certificate of Assumed Business Name.

Facility/Agency Identification No. — For facilities/agencies located in Texas, enter the facility/agency identification number issued by the State of Texas; if this number has not yet been issued by the state, enter the facility/agency’s license number. For out-of-state facilities/agencies, enter the identification number issued by the applicable regulatory authority.

National Provider Identifier No. — Enter the federal provider number assigned by CMS and/or the state survey agency, if applicable.

Outcome — Check the applicable box to indicate whether the long-term care facility/agency surrendered a license in lieu of revocation, allowed a license to expire while revocation action was pending, or withdrew the appeal of a revocation action while the action was pending.

Effective Date — Enter the date on which the license expired, the facility/agency surrendered the license, or the facility/agency withdrew the appeal.

P.

Federal or state sanctions, penalties, or enforcement actions include administrative penalties, civil monetary penalties, civil penalties, denial of payment for new admissions, termination, decertification, vendor holds, amelioration, state monitoring, directed plan of correction, directed inservice training, and temporary management; federal or state sanctions, penalties, or enforcement actions do not include compliance letters.

Note: Do not record enforcement actions initiated by DADS or by CMS against facilities/agencies located in Texas.

Facility/Agency Name — Enter the name of the long-term care facility/agency located outside the state of Texas for which this question is answered affirmatively; enter the name exactly as it appears on the filed Certificate of Assumed Business Name.

Facility/Agency Identification No. — Enter the identification number issued by the applicable regulatory authority.

National Provider Identifier No. — Enter the federal provider number assigned by CMS and/or the state survey agency, if applicable.

Type of Action and Outcome — Check all applicable boxes, and fill in each applicable blank.

1. Suspension of admissions: Visit Exit Date — Enter the date of the regulatory visit that resulted in the recommendation for suspension of admissions, if applicable.

Start Date and End Date — Enter the date range (beginning date and ending date) for which the suspension of admissions was in effect.

Individual/Entity — Enter the name of the individual or entity for which this question is answered affirmatively, and check the appropriate box to indicate the item in which this individual or entity has been identified. You may check multiple boxes, if applicable.

2. Involuntary closure: Date of Closure — Enter the effective date of the closure (the date on which the license holder received written notice of the closing order, or a later date specified in the order.)

Individual/Entity — Enter the name of the individual or entity for which this question is answered affirmatively, and check the appropriate box to indicate the item in which this individual or entity has been identified. You may check multiple boxes, if applicable.

3. Denial of payment for new admissions: Visit Exit Date — Enter the date of the regulatory visit that resulted in the imposition of denial of payment for new admissions.

Start Date and End Date — Enter the date range (beginning date and ending date) for which the denial of payment for new admissions was imposed.

Individual/Entity — Enter the name of the individual or entity for which this question is answered affirmatively, and check the appropriate box to indicate the item in which this individual or entity has been identified. You may check multiple boxes, if applicable.

4. Directed plan of correction: Visit Exit Date — Enter the date of the regulatory visit that resulted in the recommendation for directed plan of correction.

Individual/Entity — Enter the name of the individual or entity for which this question is answered affirmatively, and check the appropriate box to indicate the item in which this individual or entity has been identified. You may check multiple boxes, if applicable.

5. Termination of certification/contract: Visit Exit Date — Enter the date of the regulatory visit that resulted in the termination of certification/contract.

Date of certification/contract termination — Enter the date specified by the regulatory authority on which the facility’s certification/contract was terminated.

Individual/Entity — Enter the name of the individual or entity for which this question is answered affirmatively, and check the appropriate box to indicate the item in which this individual or entity has been identified. You may check multiple boxes, if applicable.

6. Downgrade of the status of a facility license: Effective Date — Enter the date specified by the regulatory authority on which the facility license’s status was downgraded.

Note: This remedy is used in some states other than Texas.

Individual/Entity — Enter the name of the individual or entity for which this question is answered affirmatively, and check the appropriate box to indicate the item in which this individual or entity has been identified. You may check multiple boxes, if applicable.

7. Administrative Penalty: Amount — Enter the total amount of the administrative penalty imposed.

Visit Exit Date and Imposition Date — Enter the end date of the regulatory visit, if known, that resulted in the administrative penalty and the date that the administrative penalty was imposed. If the penalty was not related to a visit, enter the imposition date only.

Check the applicable box to indicate whether the penalty has been paid. If the penalty has not been paid, explain the reason for non-payment, such as the penalty is being appealed.

Individual/Entity — Enter the name of the individual or entity for which this question is answered affirmatively, and check the appropriate box to indicate the item in which this individual or entity has been identified. You may check multiple boxes, if applicable.

8. Civil Penalty: Amount — Enter the amount of the civil penalty assessed.

Visit Exit Date — Enter the date of the regulatory visit that resulted in the civil penalty.

Check the applicable box to indicate whether the penalty has been paid. If the penalty has not been paid, explain the reason for non-payment.

Individual/Entity — Enter the name of the individual or entity for which this question is answered affirmatively, and check the appropriate box to indicate the item in which this individual or entity has been identified. You may check multiple boxes, if applicable.

9. Civil Money Penalty: Amount — Enter the amount of the civil money penalty recommended.

Visit Exit Date — Enter the date of the regulatory visit that resulted in the civil monetary penalty. If more than one visit date is associated with the penalty, enter the earliest date.

Check the applicable box to indicate whether the penalty has been paid. If the penalty has not been paid, explain the reason for nonpayment.

Individual/Entity — Enter the name of the individual or entity for which this question is answered affirmatively, and check the appropriate box to indicate the item in which this individual or entity has been identified. You may check multiple boxes, if applicable.

10. Other: Action — Enter any other enforcement action, that is, a sanction/penalty established or applied by a regulatory authority, such as amelioration, state monitoring, directed inservice training, temporary management, etc.

Date of Action — Enter the date of the enforcement action specified by the regulatory authority.

Outcome/Explanation — Enter the outcome of any other enforcement action.

Individual/Entity — Enter the name of the individual or entity for which this question is answered affirmatively, and check the appropriate box to indicate the item in which this individual or entity has been identified. You may check multiple boxes, if applicable.

Item 10 — Financial Information for Initial License Application or Change of Ownership Application

If the applicant is submitting an Initial License Application or a Change of Ownership Application, complete Item 10. If a requested data field is not applicable, enter 0. No questions should be left blank.

The financial information and accounts balances reported in Item 10 Sections A, D, E, F and G must reflect amounts and balances that exclude any intercompany transactions between related parties at a price that is not at fair value.

Intercompany transaction is defined as a financial exchange or interaction between two entities considered to be related parties (for example, receivables and payables due from one entity to the other and/or any transaction or agreement between two parties affecting the value of any account).

Related party is defined as a person or entity associated with the entity identified as the applicant in Item 5 by blood/marriage, business ownership or any association that permits either person or entity to exert control, power or influence, either directly or indirectly, over the other (for example, an owner company and its joint ventures and partnerships; an investor and its investees; common officers or directors; family members, etc.).

Control, power or influence may be exerted through familial relationships, guarantees of indebtedness, extensions of credit, or ownership of debt obligations, warrants or other securities

Fair value is defined as the price that market participants would receive if they sold the asset or would pay to transfer the liability. A fair value measurement should be determined based on the assumptions that market participants would use and develop based on the best information available in the circumstances when pricing the asset or liability.

A. Preliminary Financial Information

Provide the requested information in relation to the following unless otherwise specified:

  1. the entity identified as the applicant in Item 5 of the application;
  2. the financials of the applicant entity itself; and
  3. the applicant entity's financials that are dedicated and specific to the facility indicated in Item 1 of the application.

If the applicant has assets or liabilities covering multiple facilities, enter only the pro rata portion dedicated and specific to the facility indicated in Item 1 of the application.

Asset is defined as a facility operation-related item of value that is owned and controlled by the applicant and that has future probable economic benefit.

Liability is defined as the amount of a legally enforceable claim on the facility operation-related assets of the applicant.

Pro rata portion is defined as the specific portion of the full value of the involved assets proportionately distributed among the facilities.

Budgeted Capital — Enter the total fair value of the applicant's assets or resources budgeted to meet facility operations for the 12 months following the date of licensure approval.

Total Fixed Cost — Enter the amount of expenses related to the operation of the facility that remain constant, regardless of the volume of activity, for the 12-month period following the date of licensure approval.

Amount of Debt — Enter the total outstanding amount of any loan obligation and total liabilities. Include fines, penalties, and judgments applicable to the facility identified in Item 1 of the application (see Item 9, sections E, G, H, I, J, K and P) that will be serviced from the cash flow generated by the operation of the facility for the 12 months following the date of licensure approval.

Type of Debt — List all of the loan obligations and liabilities owed that will be serviced from the cash flow generated by facility operation (for example, loan note, bond, mortgage, debentures, etc.).

Related to Facility Operation— Check Yes if all of the debts are related to operation of the facility indicated in Item 1 of the application. Check No if any debt is not related to operation of the facility indicated in Item 1 of the application.

B. Line of Credit Information

Provide the requested information in relation to the following unless otherwise specified:

  1. the entity identified as the applicant in Item 5 of the application;
  2. the financials of the applicant entity itself; and
  3. the applicant entity's financials that are dedicated and specific to the facility indicated in Item 1 of the application.

If the applicant has assets or liabilities covering multiple facilities, enter only the pro rata portion dedicated and specific to the facility indicated in Item 1 of the application.

If additional entries are required for full disclosure, copy Item 10 of the application to use as an attachment for multiple entries.

Line of Credit — Enter the amount of funds available from a lender, or related party(ies), or affiliate(s), for facility operation-related expenditures. If the applicant does not have a line of credit available, enter 0.

Available is defined as readily accessible and unused as of the date of the application.

Name of Issuer of Line of Credit — If the applicant has a line of credit available, enter the name of the lender, or related party(ies), or affiliate(s), responsible for issuing the line of credit. Enter the name of the lender exactly as it appears on the line of credit documentation. Do not use abbreviations.

Non-Related Party — Check Yes if the line of credit is from a non-related party source. Check No if the line of credit is not from a non-related party source.

Contact Person Last Name, First Name — If the applicant has a line of credit available, enter the last name and first name of the contact person for the lender issuing the line of credit.

Area Code and Telephone No. — Enter the contact person's area code and telephone number. If a contact person for the lender is unknown, enter the area code and telephone number of the lender issuing the line of credit.

Mailing Address — Street or P. O. Box, City, State/Province, ZIP/Postal Code, Country — If the applicant has a line of credit available, enter the full mailing address of the lender issuing the line of credit.

C. Start-Up Fund Information

Provide the requested information in relation to the following unless otherwise specified:

  1. the entity identified as the applicant in Item 5 of the application;
  2. the financials of the applicant entity itself; and
  3. the applicant entity's financials that are dedicated and specific to the facility indicated in Item 1 of the application.

If the applicant has assets or liabilities covering multiple facilities, enter only the pro rata portion dedicated and specific to the facility indicated in Item 1 of the application.

If additional entries are required for full disclosure, copy Item 10 of the application to use as an attachment for multiple entries.

Start-Up Funds — Enter the total amount of start-up funds from each source.

Start-Up funds is defined as monies used to acquire, or to prepare to begin the operations of, a nursing facility business prior to the date of licensure approval (for example, start up funds may be used to purchase initial supplies, equipment, furniture, and/or building(s) to start the operation).

Name of Issuer or Source of Start-Up Funds — Enter the legal name of the individual/entity who is the source of the start-up funds.

Non-Related Party — Check Yes if the start-up funds are from a non-related party source. Check No if the start-up funds are not from a non-related party source.

Contact Person Last Name, First Name — Enter the last name and first name of the contact person for the individual/entity who is the source of the start-up funds.

Area Code and Telephone No. — Enter the area code and telephone number of the contact person for the individual/entity who is the source of the start-up funds. If a contact person for the source of the start-up funds is unknown, enter the area code and telephone number of the individual/entity who is the source of the start-up funds.

Mailing Address — Street or P. O. Box, City, State/Province, ZIP/Postal Code, Country — Enter the full mailing address of the individual/entity who is the source of the start-up funds.

Payment Schedule— Check the applicable box to indicate the frequency with which the applicant is obligated to make a payment to repay the issuer or source of the start-up funds. If the applicant does not make payments on a monthly, quarterly, or yearly basis, check the box for Other and enter the frequency in the space provided. If the start-up funds do not have to be repaid, check the box for No Repayment, and enter the nature of the funds (for example, a gift, grant or the applicant's own funds).

Amount Due Per Installment — Enter the amount of payment due, according to the payment schedule as indicated above.

Term of Loan — Enter the interest rate and the length of the repayment period (for example, 10% interest rate for 15 years).

Priority — Enter the priority of this payment in relation to other creditors (for example, first - before all other creditors; last - after all other obligations are met, etc.).

Result of Default — Enter the consequence of the applicant's failure to make a payment when due, such as foreclosure in the event that the debt is secured by a mortgage or deed of trust.

Other Terms — Enter and clarify any other terms that impact repayment or ownership distribution. (for example, fine or penalties for late payments, terms or conditions that require immediate, full payment of entire loan, or exchange of ownership, etc.).

Total Start-Up Funds — Enter the total amount of start-up funds.

D. General Financial Information

Provide the requested information in relation to the following unless otherwise specified:

  1. the entity identified as the applicant in Item 5 of the application;
  2. the financials of the applicant entity itself; and
  3. the applicant entity's financials that are dedicated and specific to the facility indicated in Item 1 of the application.

If the applicant has assets or liabilities covering multiple facilities, enter only the pro rata portion dedicated and specific to the facility indicated in Item 1 of the application.

Monthly Mortgage Payment(s) — If the applicant owns the real property (including building(s) and land) on which the facility identified in Item 1 of the application is located and that property is subject to a mortgage, enter the monthly amount of the mortgage payment(s). If the applicant does not have a mortgage payment, enter 0.

Monthly Facility Lease Payment(s) — If the applicant leases the building(s) in which the facility identified in Item 1 of the application is located, enter the monthly amount of lease payment(s). If the applicant does not have a lease payment, enter 0.

Estimated Monthly Management Fee Expense — If the facility identified in Item 1 of the application is operated by, or proposed to be operated by, a management company (as defined in Item 6), enter the estimated monthly amount of management fees. If the facility is not operated by, or proposed to be operated by, a management company, enter 0.

Delinquent Taxes/Workers' Compensation — Check Yes if the applicant is currently delinquent on any tax or workers' compensation payments. Check No if the applicant is not currently delinquent on any tax or workers' compensation payments.

Delinquent Tax is defined as a specific tax assessment whose due date has passed and, by statute, any appeal rights have expired (for example, income tax, payroll tax, unemployment tax, franchise tax).

Note: The examples listed are indicative only and are not intended to be exhaustive. This question pertains to any controlling person(s) in the applicant's entire ownership structure (Item 5 individual(s)/entity(ies)).

E. Balance Sheet or Statement of Financial Position

Provide the requested information in relation to the following unless otherwise specified:

  1. the entity identified as the applicant in Item 5 of the application;
  2. the financials of the applicant entity itself; and
  3. the applicant entity's financials that are dedicated and specific to the facility indicated in Item 1 of the application.

If the applicant has assets or liabilities covering multiple facilities, enter only the pro rata portion dedicated and specific to the facility indicated in Item 1 of the application.

Balance Sheet is defined as a financial document that shows what the individual or entity owns (assets), what it owes (liabilities), and what its ownership position is (owner's equity) at a specific point in time. (Applicants are responsible for ensuring the accuracy of the reported data. Example: Total Assets = Liabilities + Owner's equity/Change in Net Assets.)

Equity is defined as an individual's or entity's value in an asset less any obligation associated with that asset.

Current Assets

Cash and/or Cash Equivalents — Enter the ending balance of cash on hand and all items that a bank accepted for deposit (currency, coins, checks, money orders, electronic fund transfers, etc.), and the brokerage account ending balance that is readily accessible and transferable in cash as of the date of the application, excluding allowance for doubtful accounts. If the applicant did not have cash or cash equivalents as of the date of the application, enter 0.

Ending balance is defined as the value in an account that equals the net of credits and debits for that account as of the date of the application.

Allowance for doubtful accounts is defined as an anticipated dollar amount set aside to provide for accounts receivables that are estimated to be uncollectible.

Net Operating Receivables — Enter the ending balance of current payments that were due for goods or services provided in the normal course of business as of the date of the application, excluding allowance for doubtful accounts. If the applicant did not have operating receivables as of the date of the application, enter 0.

Prepaid Expenses — Enter the ending balance of expenditures for which the applicant paid in the current accounting cycle but did not completely use or consume until the next accounting cycle (insurance, advertising, rent, etc.) as of the date of the application. If the applicant did not have any prepaid expenses as of the date of the application, enter 0.

Other Receivables — Enter the ending balance of payments for goods or services provided outside the normal course of business (advances to employees, tax refunds, insurance receipts, deposits, interest receivables, dividend receivables, etc.) as of the date of the application. If the applicant did not have other receivables as of the date of the application, enter 0.

Total Current Assets — Enter all of the applicant's current assets by adding Cash and/or Cash Equivalents, Net Operating Receivables, Prepaid Expenses and Other Receivables as of the date of the application.

Fixed Assets

Fixed asset is defined as an asset that has a useful life of more than one year, is acquired for use in the normal course of business, and is not intended for resale.

Land — Enter the ending balance of any land held by the applicant for use in the normal course of business or for investment purposes as of the date of the application. If the applicant did not hold any land as of the date of the application, enter 0.

Building — Enter the ending balance less accumulated depreciation of building(s) held by the applicant for use in the normal course of business or for investment purposes as of the date of the application. If the applicant did not hold any building(s) as of the date of the application, enter 0.

Depreciation is defined as the periodic allocation of the cost of a tangible long-lived asset over its useful life.

Equipment — Enter the ending balance less accumulated depreciation of equipment (medical equipment, tools, machinery, etc.) the applicant owned as of the date of the application. If the applicant did not own equipment as of the date of the application, enter 0.

Leasehold Improvements — Enter the ending balance less accumulated amortization of upgrades the applicant (lessee) made to the leased property that will revert to the lessor at the expiration of the lease term (wall panels, wallpaper, floor coverings, permanent fixtures, etc.) as of the date of the application. If the applicant did not make any upgrades to the leased property as of the date of the application, enter 0.

Amortization is defined as the periodic allocation of the cost of an intangible asset over its useful life.

Intangible asset is defined as a long-term asset that has no physical substance but has value based on rights or privileges accruing to the owner.

Intangible Assets — Enter the ending balance less accumulated amortization of the applicant's intangible assets, such as goodwill costs, as of the date of the application. If the applicant did not have any goodwill costs or other intangible assets as of the date of the application, enter 0.

Goodwill is defined as the value assigned to an intangible asset, such as the favor or prestige of a business; goodwill represents the difference between the purchase price of an asset and the amount that normally would be paid on the open market by willing buyers when no exceptional circumstances, such as liquidation, shortages or emergency influence the value of that asset.

Other Assets — If the applicant owned other assets, enter the ending balance less accumulated depreciation of the assets, excluding intangible assets, as of the date of the application. If the applicant did not own other assets as of the date of the application, enter 0.

Total Fixed Assets — Enter all of the applicant's fixed assets by adding Land, Building, Equipment, Leasehold Improvements, Intangible Assets and Other Assets as of the date of the application. If the applicant did not have any fixed assets as of the date of the application, enter 0.

Total Assets — Enter all of the applicant's total assets by adding the Total Current Assets and Total Fixed Assets as of the date of the application.

Liability and Owner's Equity/Change in Net Assets

Current Liabilities — Enter the total amount of the ending balance of the applicant's debts, obligated payments and total liabilities. Include fines, penalties and judgments applicable to the facility identified in Item 1 of the application (see Item 9, sections E, G, H, I, J, K and P) payable within 12 months of the balance sheet date as of the date of the application. If the applicant did not have any current liabilities as of the date of the application, enter 0.

Long-Term Liabilities — Enter the total amount of the ending balance of the applicant's debts, obligated payments and total liabilities. Include fines, penalties and judgments applicable to the facility identified in Item 1 of the application (see Item 9, sections E, G, H, I, J, K and P) payable after 12 months from the balance sheet date as of date of the application. If the applicant did not have any long-term liabilities as of the date of the application, enter 0.

Owner's Equity/Change in Net Assets — Enter the combined value, after all claims have been paid, of all owner(s) or shareholder(s) of the business entity disclosed in Item 5 of the application as of the date of the application. If the applicant did not have owner's equity as of the date of the application, enter 0.

Note: If the applicant is a nonprofit organization, enter the excess of what the applicant owns over what it has borrowed and still owes as of the date of the application. If the applicant did not have net assets as of the date of the application, enter 0.

Total Liability and Owner's Equity/Change in Net Assets — Enter all liabilities and owner's equity/change in net assets by adding Current Liabilities, Long-term Liabilities, and Owner's Equity/Change in Net Assets as of the date of the application.

F. Projected Balance Sheet or Projected Statement of Financial Position

Provide the requested information in relation to the following unless otherwise specified:

  1. the entity identified as the applicant in Item 5 of the application;
  2. the financials of the applicant entity itself; and
  3. the applicant entity's financials that are dedicated and specific to the facility indicated in Item 1 of the application.

If the applicant has assets or liabilities covering multiple facilities, enter only the projected pro rata portion dedicated and specific to the facility indicated in Item 1 of the application. (Applicants are responsible for ensuring the accuracy of the reported data. Example: Total Assets = Liabilities + Owner's equity/Change in Net Assets.)

Projected is defined as prospective financial statements that include one or more hypothetical assumptions.

Projection Period End Date — Enter the ending month and year of the projection period.

Projection Period is defined as the full 12-calendar-month period immediately following the application date (for example, if the application date is March 15, 2006, then the Projection Period will be from April 01, 2006 through March 31, 2007).

Current Assets

Cash and/or Cash Equivalents — Enter the projected ending balance of cash on hand and all items that a bank accepted for deposit (currency, coins, checks, money orders, electronic fund transfers, etc.) for the projection period, excluding projected allowance for doubtful accounts. If the applicant will not have cash or cash equivalents at the end of the projection period, enter 0.

Net Operating Receivables — Enter the projected ending balance of payments due for goods or services provided in the normal course of business for the projection period, excluding projected allowance for doubtful accounts. If the applicant will not have operating receivables at the end of the projection period, enter 0.

Prepaid Expenses — Enter the projected ending balance of expenditures for which the applicant will prepay in the projection period but will not completely use or consume until the next accounting cycle (insurance, advertising, rent, etc.). If the applicant will not have any prepaid expenses at the end of the projection period, enter 0.

Other Receivables — Enter the projected ending balance of payments for goods or services provided outside the normal course of business (advances to employees, tax refunds, insurance receipts, deposits, interest receivables, dividend receivables, etc.) for the projection period. If the applicant will not have other receivables at the end of the projection period, enter 0.

Total Current Assets — Enter all of the applicant's projected current assets by adding Cash and/or Cash Equivalents, Net Operating Receivables, Prepaid Expenses, and Other Receivables for the projection period.

Fixed Assets

Land — Enter the projected ending balance of any land held by the applicant for use in the normal course of business or for investment purposes for the projection period. If the applicant will not hold any land at the end of the projection period, enter 0.

Building — Enter the projected ending balance less projected accumulated depreciation of any building(s) held by the applicant for use in the normal course of business or for investment purposes for the projection period. If the applicant will not hold any building(s) at the end of the projection period, enter 0.

Equipment — Enter the projected ending balance less any accumulated depreciation of the equipment (medical equipment, tools, machinery, etc.) that the applicant will own for the projection period. If the applicant will not own equipment at the end of the projection period, enter 0.

Leasehold Improvements — Enter the projected ending balance less any accumulated amortization of the upgrades the applicant (lessee) will make to the leased property that reverted or will revert to the lessor at the expiration of the lease term (wall panels, wallpaper, floor coverings, permanent fixtures, etc.) for the projection period. If the applicant will not make any upgrades to the leased property at the end of the projection period, enter 0.

Intangible Assets — Enter the projected ending balance less accumulated amortization of the applicant's intangible assets, such as goodwill costs, for the projection period. If the applicant will not have any goodwill costs or other intangible assets at the end of the projection period, enter 0.

Other Assets — If the applicant owned other assets, enter the projected ending balance less accumulated depreciation of the assets, excluding intangible assets, for the projection period. If the applicant will not own other assets at the end of the projection period, enter 0.

Total Fixed Assets — Enter all of the applicant's projected fixed assets by adding Land, Building, Equipment, Leasehold Improvements, Intangible Assets, and Other Assets for the projection period. If the applicant will not have any fixed assets at the end of the projection period, enter 0.

Total Assets — Enter all of the applicant's projected total assets by adding the Total Current Assets and Total Fixed Assets for the projection period.

Liability and Owner's Equity/Change in Net Assets

Current Liabilities — Enter the total projected ending balance of the applicant's debts, obligated payments and total liabilities. Include fines, penalties and judgments applicable to the facility identified in Item 1 of the application (see Item 9, sections E, G, H, I, J, K and P) that are payable within the 12-month projection period. If the applicant will not have any current liabilities at the end of the projection period, enter 0.

Long-Term Liabilities — Enter the total projected ending balance of the applicant's debts, obligated payments and total liabilities. Include fines, penalties and judgments applicable to the facility identified in Item 1 of the application (see Item 9, sections E, G, H, I, J, K and P) that are payable after 12 months from the projected balance sheet date for the projection period. If the applicant will not have any long-term liabilities at the end of the projection period, enter 0.

Owner's Equity/Change in Net Assets — Enter the projected combined value, after all projected claims will be paid, of all owner(s) or shareholder(s) of the business entity disclosed in Item 5 of the application for the projection period. If the applicant will not have owner's equity/change in net assets at the end of the projection period, enter 0.

Note: If the applicant is a nonprofit organization, enter the projected excess amount of what the applicant will own over what it has borrowed and will still owe at the end of the projection period. If the applicant will not have net assets at the end of the projection period, enter 0.

Total Liability and Owner's Equity/Change in Net Assets — Enter all of the applicant's projected liabilities and projected owner's equity/change in net assets by adding Current Liabilities, Long-term Liabilities and Owner's Equity/Change in Net Assets for the projection period.

G. Projected Income Statement or Projected Statement of Activities and Changes in Net Assets or Fund Balances

Provide the requested information in relation to the following unless otherwise specified:

  1. the entity identified as the applicant in Item 5 of the application;
  2. the financials of the applicant entity itself; and
  3. the applicant entity's financials that are dedicated and specific to the facility indicated in Item 1 of the application.

If the applicant has projected revenues or projected expenses covering multiple facilities, enter only the projected pro rata portion dedicated and specific to the facility indicated in Item 1 of the application.

Income Statement is defined as a statement that summarizes a business's revenues and expenses for a specific cycle of operation; it reflects a business's operating performance by identifying the sources of income and expense that result in a final income or loss amount.

Projection Period End Date — Enter the ending month and year of the projection period.

Revenue

Routine Services — Private Pay — Enter the projected total amount the applicant will earn for routine care and services to private pay residents (individuals who pay for care through personal means, including personal insurance) for the projection period. If the applicant will not earn any payment from private pay sources during the projection period, enter 0.

Routine Services — Medicare — Enter the projected total amount the applicant will earn for routine care and services to residents who will receive Medicare benefits for the projection period. If the applicant will not earn any payment from Medicare sources during the projection period, enter 0.

Routine Services — Medicaid — Enter the projected total amount the applicant will earn for routine care and services to residents who will receive Medicaid benefits for the projection period. If the applicant will not earn any payment from Medicaid sources during the projection period, enter 0.

Routine Services — Other — Enter the projected total amount the applicant will earn for routine care and services to residents with payment sources other than private pay, Medicare and Medicaid for the projection period. If the applicant will not earn any monies from sources other than private pay, Medicare and Medicaid during the projection period, enter 0.

Ancillary Services — Enter the projected total amount that the applicant will earn for non-routine care and services (therapies, radiology, laboratory, etc.) for the projection period. If the applicant will not earn any monies for providing ancillary services during the projection period, enter 0.

Interest Income — Enter the projected facility operation-related amount of interest income the applicant will earn from cash deposits in financial institution(s), loan(s) made to borrower(s) or other sources of interest income for the projection period. If the applicant will not earn any interest income during the projection period, enter 0.

Other Income — Enter the projected facility operation-related amount of income that will be generated from any activity outside of Routine Services, Ancillary Services and Interest Income for the projection period. If the applicant will not generate other income during the projection period, enter 0.

Note: If the applicant is a nonprofit organization, enter the projected amount of revenue that the applicant will generate from grants, contributions, or any other source. If the applicant will not generate other income during the projection period, enter 0.

Total Revenue — Enter the projected total revenue by adding Routine Services - Private Pay, Routine Services - Medicare, Routine Services - Medicaid, Routine Services - Other, Ancillary Services, Interest Income and Other Income for the projection period.

Operating Expenses

Direct-Care Staff Cost — Enter the projected total amount the applicant will incur for direct-care staff salaries/benefits for the projection period. If the applicant will not incur direct-care staff cost during the period, enter 0.

Direct-Care is defined as resident care provided by nursing personnel (registered nurses, licensed vocational nurses, medication aides, restorative aides, certified nurse aides, registered respiratory therapists and certified respiratory therapy technicians) in order to carry out the physician's planned regimen of total resident care.

Other Resident Care Cost — Enter the projected total amount the applicant will incur for staff salaries/benefits, services and supplies associated with resident care costs other than direct-care staff costs (social work, activity, therapy, medical director, medical record, medical equipment, radiology, pharmacy, laboratory, etc.) for the projection period. If the applicant will not incur any other resident care cost during the projection period, enter 0.

Dietary Cost — Enter the projected total amount the applicant will incur for staff salaries/benefits, services and supplies (perishable/non-perishable food, utensils, napkins, containers, etc.) associated with dietary services for the projection period. If the applicant will not incur any dietary cost during the projection period, enter 0.

Facility and Operations Cost — Enter the projected total amount the applicant will incur for staff salaries/benefits, services and supplies associated with daily facility operations, including mortgage interest (maintenance, laundry, housekeeping, waste disposal, facility operation-related equipment, mortgage/lease, utilities, taxes, bad debt, operation interest expense, etc.) for the projection period. If the applicant will not incur any facility and operations cost during the projection period, enter 0.

Administrative Cost — Enter the projected total amount the applicant will incur for staff salaries/benefits, services, supplies and fees associated with administrative functions (billing, management, clerical, general office, insurance, training, seminars, subscriptions, etc.) for the projection period. If the applicant will not incur any administrative cost during the projection period, enter 0.

Payroll Taxes and Workers' Compensation — Enter the projected total amount the applicant will incur for payroll taxes and workers' compensation for the projection period. If the applicant will not incur any payroll taxes or workers' compensation during the projection period, enter 0.

Payroll taxes are defined as the portion of taxes levied on employees' salaries or income of self-employed individuals, including Social Security taxes, state unemployment taxes and federal unemployment taxes that the applicant paid, excluding the amount the applicant forwards on behalf of the employee.

Workers' compensation is defined as payments made by the applicant to the Workers' Compensation Fund or other payments made for workers involved in specific job-related injuries.

Total Operating Expenses — Enter the projected total operating expenses by adding Direct-care Staff Cost, Other Resident Care Cost, Dietary Cost, Facility and Operations Cost, Administrative Cost, and Payroll Taxes and Workers' Compensation for the projection period.

Non-Operating Expenses

Interest Expense and Penalties — Enter the projected total amount of non-operating interest and/or penalty that the applicant will pay on any borrowed non-operating funds for the projection period. If the applicant will not pay any interest expense during the projection period, enter 0.

Depreciation — Enter the projected total amount of depreciation cost for the projection period. If the applicant will not have any depreciation during the projection period, enter 0.

Amortization — Enter the projected amortization cost for the projection period. If the applicant will not have any amortization costs during the projection period, enter 0.

Other Non-operating Expense — Enter the projected total amount of non-operating expenses from sources other than interest expense, depreciation, and amortization (litigation, claims, assessments, fire loss, etc.) that the applicant will pay for the projection period. If the applicant will not incur other non-operating expenses during the projection period, enter 0.

Total Non-operating Expenses — Enter the projected total non-operating expenses by adding Interest Expense, Depreciation, Amortization and Other Non-Operating Expense for the projection period. If the applicant will not incur any non-operating expenses during the projection period, enter 0.

Income Tax Expense — Enter the projected amount of federal government levy on the projected taxable income for the projection period. If the applicant will not be subject to a federal government levy on taxable income during the projection period, enter 0.

Total Expenses — Enter the projected total expenses by adding Total Operating Expenses, Total Non-Operating Expenses and Income Tax Expenses for the projection period. If the applicant will not incur any expense during the projection period, enter 0.

Net Income/Revenue (loss) — Enter the applicant's projected profit/revenue or loss by subtracting Total Expenses from Total Revenue for the projection period. If this figure represents a loss, or a greater amount of expenses than of revenue, place parentheses around it.

Item 11 — Financial Information for License Renewal Application

If the applicant is submitting a License Renewal Application, complete Item 11.

If a requested data field is not applicable, enter 0. No questions should be left blank (with the exception of prior year information for probationary license holders in Item 11, D and E).

The financial information and accounts balances reported in this section (Item 11, Sections A, C, D and E) must reflect amounts and balances that exclude any intercompany transactions between related parties at a price that is not at fair value.

Intercompany transaction is defined as a financial exchange or interaction between two entities considered to be related parties (for example, receivables and payables due from one entity to the other and/or any transaction or agreement between two parties affecting the value of any account).

Related party is defined as a person or entity associated with the entity identified as the applicant in Item 5 by blood/marriage, business ownership or any association that permits either person or entity to exert control, power, or influence, either directly or indirectly, over the other (for example, an owner company and its joint ventures and partnerships; an investor and its investees; common officers or directors; family members, etc.).

Fair value is defined as the price that market participants would receive if they sold the asset or would pay to transfer the liability. A fair value measurement should be determined based on the assumptions that market participants would use and developed based on the best information available in the circumstances when pricing the asset or liability.

Control, power or influence may be exerted through familial relationships, guarantees of indebtedness, extensions of credit, or ownership of debt obligations, warrants or other securities.

Provide the requested information in relation to the following unless otherwise specified:

  1. the entity identified as the applicant in Item 5 of the application;
  2. the financials of the applicant entity itself; and
  3. the applicant entity's financials that are dedicated and specific to the facility indicated in Item 1 of the application.

If the applicant has assets or liabilities covering multiple facilities, enter only the pro rata portion dedicated and specific to the facility indicated in Item 1 of the application.

Asset is defined as a facility operation-related item of value that is owned and controlled by the applicant and that has future probable economic benefit.

Liability is defined as the amount of a legally enforceable claim on the facility operation-related assets of the applicant.

Pro rata portion is defined as the specific portion of the full value of the involved assets proportionately distributed among the facilities.

A. Accounts Receivable Information

Does the applicant write off uncollectible accounts receivable? — Check Yes if the nursing facility writes off accounts receivable that are deemed uncollectible. Check No if the nursing facility does not write off accounts that are deemed uncollectible.

If Yes, how often? — Check the applicable box to indicate the most applicable frequency with which the applicant writes off accounts that are deemed uncollectible, on a monthly, quarterly or yearly basis. (for example, if the applicant writes off uncollectible accounts receivable monthly or more frequently than monthly, that is, every two weeks, then indicate monthly. If the applicant writes off uncollectible accounts receivable quarterly or less frequently than monthly, that is, every two months, then indicate quarterly. If the applicant writes off uncollectible account receivables yearly or less frequently than quarterly, that is, every two years, then indicate yearly.)

Accounts receivable is defined as money owed the applicant that has not been collected yet or that is set to be collected at a later, specified date.

Accrual accounting basis is defined as an accounting system in which revenues and expenses are recognized in the period in which they arise regardless of when the payment for the revenue or the expenditure actually occurs.

List age of accounts receivable — Enter the total amount of accounts receivable that are between 0 and 30 days old; provide the same information for the remaining time frames (31 to 60 days, 61 to 90 days, 91 to 120 days, and 121 days and over).

Total Accounts Receivable — Enter the total amount of all accounts receivable in the Current Year (the total of the 0 to 30 days, 31 to 60 days, 61 to 90 days, 91 to 120 days, and 121 days and over accounts receivable). This sum of accounts receivable should be 100% of the facility's total accounts receivable.

Current Year is defined as the most recent full 12-calendar-month period with the ending date no more than 60 days prior to the date of application (for example, if the application date is March 15, 2016, then the 12-month-current-year period could be February 1, 2015 through January 31, 2016 or March 1, 2015 through February 29, 2016).

Note: For Probationary License holders (one-year-duration license for new owners not previously licensed), the Current Year reported may be less than 12-calendar-months due to the requirement to submit the Renewal Application at least 45 days prior to license expiration and may include at least a portion of the start-up period.

Start-Up period is defined as the period of time in which the applicant begins to acquire, or prepares to begin the operations of, a nursing facility business prior to the date of licensure approval (for example, the period of time in which applicant purchased initial supplies, equipment, furniture and/or building(s) to start the operation).

For example: A probationary license issued effective May 1, 2015 would expire on April 30, 2016. As an applicant is required to submit their renewal application at least 45 days prior to expiration, the renewal for this probationary license would be due by March 15, 2016. Since the Current Year reported requires full calendar months and may not end more than 60 days prior to the date of the application, the end date of this applicant's Current Year could be January 31, 2016.

Example 1: If Start-Up period began on or before February 1, 2015 — When including the Start-Up period, the Current Year reporting period is 12 calendar months.

Example 2: If Start-Up period began on April 1, 2015 — When including the Start-Up period, the Current Year reporting period is 10 calendar months.

B. Line of Credit Information

Provide the requested information in relation to the following unless otherwise specified:

  1. the entity identified as the applicant in Item 5 of the application;
  2. the financials of the applicant entity itself; and
  3. the applicant entity's financials that are dedicated and specific to the facility indicated in Item 1 of the application.

If the applicant has assets or liabilities covering multiple facilities, enter only the pro rata portion dedicated and specific to the facility indicated in Item 1 of the application.

If additional entries are required for full disclosure, copy Item 11, Part 2, of the application to use as an attachment for multiple entries.

Line of Credit — Enter the amount of funds available from a lender, or related party(ies), or affiliate(s), for facility operation-related expenditures. If the applicant does not have a line of credit available, enter 0.

Available is defined as readily accessible and unused as of the date of the application.

Name of Issuer of Line of Credit — If the applicant has a line of credit available, enter the name of the lender, or related party(ies), or affiliate(s), responsible for issuing the line of credit. Enter the name of the lender exactly as it appears on the line of credit documentation. Do not use abbreviations.

Non-Related Party — Check Yes if the line of credit is from a non-related party source. Check No if the line of credit is not from a non-related party source.

Contact Person Last Name, First Name — If the applicant has a line of credit available, enter the last name and first name of the contact person for the lender issuing the line of credit.

Area Code and Telephone No. — Enter the contact person's area code and telephone number. If a contact person for the lender is unknown, enter the area code and telephone number of the lender issuing the line of credit.

Mailing Address — Street or P. O. Box, City, State/Province, ZIP/Postal Code, Country — If the applicant has a line of credit available, enter the full mailing address of the lender issuing the line of credit.

C. General Financial Information

Provide the requested information in relation to the following unless otherwise specified:

  1. the entity identified as the applicant in Item 5 of the application;
  2. the financials of the applicant entity itself; and
  3. the applicant entity's financials that are dedicated and specific to the facility indicated in Item 1 of the application.

If the applicant has assets or liabilities covering multiple facilities, enter only the pro rata portion dedicated and specific to the facility indicated in Item 1 of the application.

Monthly Mortgage Payment(s) — If the applicant owns the property (including buildings and land) on which the facility identified in Item 1 of the application is located and that property is subject to a mortgage, enter the monthly amount of the mortgage payment(s). If the applicant does not have a mortgage payment, enter 0.

Monthly Facility Lease Payment(s) — If the applicant leases the building(s) in which the facility identified in Item 1 of the application is located, enter the monthly amount of lease payment(s). If the applicant does not have a lease payment, enter 0.

Average Monthly Management Fee Expense — If the facility identified in Item 1 of the application is operated by, or proposed to be operated by, a management company (as defined in Item 3), enter the average monthly amount of management fees. If the facility is not operated by, or proposed to be operated by, a management company, enter 0.

Delinquent Taxes/Workers' Compensation — Check Yes if the applicant is currently delinquent on any tax or workers' compensation payments. Check No if the applicant is not currently delinquent on any tax or workers' compensation payments.

Delinquent Tax is defined as a specific tax assessment whose due date has passed and, by statute, any appeal rights have expired (for example, income tax, payroll tax, unemployment tax, franchise tax).

Note: The examples listed are indicative only and are not intended to be exhaustive. This question pertains to any controlling person(s) in the applicant's entire ownership structure (Item 5 individual(s)/entity(ies).

D. Balance Sheet or Statement of Financial Position for Current Year and Two Prior Years

Provide the requested information in relation to the following unless otherwise specified:

  1. the entity identified as the applicant in Item 5 of the application;
  2. the financials of the applicant entity itself; and
  3. the applicant entity's financials that are dedicated and specific to the facility indicated in Item 1 of the application.

If the applicant has assets or liabilities covering multiple facilities, enter only the pro rata portion dedicated and specific to the facility indicated in Item 1 of the application.

Balance Sheet is defined as a financial document that shows what the individual or entity owns (assets), what it owes (liabilities), and what its ownership position is (owner's equity) at a specific point in time. (Applicants are responsible for ensuring the accuracy of the reported data. Example: Total Assets = Liabilities + Owner's equity/Change in Net Assets.)

Equity is defined as an individual's or entity's value in an asset less any obligation associated with that asset.

Current Year is defined as the most recent full 12-calendar-month period with the ending date no more than 60 days prior to the date of application (for example, if the application date is March 15, 2016, then the 12-month-current-year period will be February 1, 2015 through January 31, 2016).

Note: For Probationary License holders (one-year-duration license for new owners not previously licensed), the Current Year reported may be less than 12-calendar-months due to the requirement to submit the Renewal Application at least 45 days prior to license expiration and may include at least a portion of the start-up period.

Start-Up period is defined as the period of time in which the applicant begins to acquire, or prepares to begin the operations of, a nursing facility business prior to the date of licensure approval (for example, the period of time in which applicant purchased initial supplies, equipment, furniture and/or building(s) to start the operation).

For example: A probationary license issued effective May 1, 2015 would expire on April 30, 2016. As an applicant is required to submit their renewal application at least 45 days prior to expiration, the renewal for this probationary license would be due by March 15, 2016. Since the Current Year reported requires full calendar months and may not end more than 60 days prior to the date of the application, the end date of this applicant's Current Year could be January 31, 2016.

Example 1: If Start-Up period began on or before February 1, 2015 — When including the Start-Up period, the Current Year reporting period is 12 calendar months.

Example 2: If Start-Up period began on April 1, 2015 — When including the Start-Up period, the Current Year reporting period is 10 calendar months.

Prior Year One is defined as the full 12-calendar-month period immediately preceding the Current Year (refer to the definition for Current Year). For example, if the Current Year began on March 1, 2015, then Prior Year One was March 1, 2014 through February 28, 2015.

Prior Year Two is defined as the full 12-calendar-month period immediately preceding Prior Year One. For example, if Prior Year One began on March 1, 2014, then Prior Year Two was March 1, 2013 through February 28, 2014.

Note: If this is the first renewal of a regular license, Prior Year One may include at least a portion of the start-up period and Prior Year Two should leave each line item blank.

An applicant who currently has a probationary license is not required to report financial data for the prior years and should leave each line item blank.

 

Current Assets

Cash and/or Cash Equivalents — Enter the ending balance of cash on hand and all items that a bank accepted for deposit (currency, coins, checks, money orders, electronic fund transfers, etc.), and the brokerage account ending balance that is readily accessible and transferable in cash for the current year and the prior years, excluding allowance for uncollectible accounts. If the applicant did not have cash or cash equivalents during the current year or the prior years, enter 0.

Ending balance is defined as the value in an account that equals the net of credits and debits for that account as of the end date of the current year, or prior year, as applicable.

Net Operating Receivables — Enter the ending balance of current payments that were due for goods or services provided in the normal course of business for the current year and the prior years. If the applicant did not have operating receivables at the end of the current year or the prior years, enter 0.

Prepaid Expenses — Enter the ending balance of expenditures for which the applicant paid in the applicable accounting cycle but did not completely use or consume until the next accounting cycle (insurance, advertising, rent, etc.) for the current year and the prior years. If the applicant did not have any prepaid expenses at the end of the current year or the prior years, enter 0.

Other Receivables — Enter the ending balance of payments for goods or services provided outside the normal course of business (advances to employees, tax refunds, insurance receipts, deposits, interest receivables, dividend receivables, etc.) for the current year and the prior years. If the applicant did not have other receivables at the end of the current year or the prior years, enter 0.

Total Current Assets — Enter all of the applicant's current assets by adding Cash and/or Cash Equivalents, Net Operating Receivables, Prepaid Expenses, and Other Receivables for the current year and the prior years.

Fixed Assets

Fixed asset is defined as an asset that has a useful life of more than one year, is acquired for use in the normal course of business, and is not intended for resale.

Land — Enter the ending balance of any land that was held by the applicant for use in the normal course of business or for investment purposes for the current year and the prior years. If the applicant did not hold any land at the end of the current year or the prior years, enter 0.

Depreciation is defined as the periodic reduction of the value of an asset over the useful life of the asset, or the recovery of the asset's cost over the useful life of the asset.

Building — Enter the ending balance less any accumulated depreciation of any building(s) that was held by the applicant for use in the normal course of business or for investment purposes for the current year and the prior years. If the applicant did not hold any building at the end of the current year or the prior years, enter 0.

Equipment — Enter the ending balance less any accumulated depreciation of the equipment (medical equipment, tools, machinery, etc.) that the applicant owned for the current year and the prior years. If the applicant did not own equipment at the end of the current year or the prior years, enter 0.

Leasehold Improvements — Enter the ending balance less any accumulated amortization of the upgrades the applicant (lessee) made to the leased property that reverted or will revert to the lessor at the expiration of the lease term (wall panels, wallpaper, floor coverings, permanent fixtures, etc.) for the current year and the prior years. If the applicant did not make any upgrades to the leased property at the end of the current year or the prior years, enter 0.

Amortization is defined as the periodic allocation of the cost of an intangible asset over its useful life.

Intangible asset is defined as a long-term asset that has no physical substance but has a value based on rights or privileges accruing to the owner.

Intangible Assets — Enter the ending balance less any accumulated amortization of the applicant's intangible assets, such as goodwill costs, for the current year and the prior years. If the applicant did not have any goodwill costs or other intangible assets at the end of the current year or the prior years, enter 0.

Goodwill is defined as the value assigned to an intangible asset, such as the favor or prestige of a business; goodwill represents the difference between the purchase price of an asset and the amount that normally would be paid on the open market by willing buyers when no exceptional circumstances, such as liquidation, shortages, or emergency, influence the value of that asset.

Other Assets — If the applicant owned other assets, enter the ending balance less any accumulated depreciation of the assets, excluding intangible assets, for the current year and the prior years. If the applicant did not own other assets at the end of the current year or the prior years, enter 0.

Total Fixed Assets — Enter all of the applicant's fixed assets by adding Land, Building, Equipment, Leasehold Improvements, Intangible Assets, and Other Assets for the current year and the prior years. If the applicant did not have any fixed assets at the end of the current year or the prior years, enter 0.

Total Assets — Enter all of the applicant's total assets by adding the Total Current Assets and Total Fixed Assets for the current year and the prior years.

Liability and Owner's Equity/Change in Net Assets

Current Liabilities — Enter the total amount of the ending balance of the applicant's debts, obligated payments, and total liabilities. Include fines, penalties, and judgments applicable to the facility identified in Item 1 of the application (see Item 9, sections E, G, H, I, J, K and P) payable within 12 months of the balance sheet date for the current year and the prior years. If the applicant did not have any current liabilities for the current year and the prior years, enter 0.

Long-term Liabilities — Enter the total amount of the ending balance of the applicant's debts, obligated payments, and total liabilities. Include fines, penalties, and judgments applicable to the facility identified in Item 1 of the application see Item 9, sections E, G, H, I, J, K and P) payable after 12 months from the balance sheet date for the current year and the prior years. If the applicant did not have any long-term liability for the current year and the prior years, enter 0.

Owner's Equity/Change In Net Assets — Enter the combined value, after all claims have been paid, of all owner(s) or shareholder(s) of the business entity disclosed in Item 5 of the application for the current year and the prior years. If the applicant did not have owner's equity at the end of the current year or the prior years, enter 0.

Note: If the applicant is a nonprofit organization, enter the excess of what the applicant owns over what it has borrowed and still owes for the current year and the prior years. If the applicant did not have net assets for the current year and the prior years, enter 0.

Total Liability and Owner's Equity/Change in Net Assets — Enter all liabilities and owner's equity/change in net assets by adding Current Liabilities, Long-term Liabilities, and Owner's Equity/Change in Net Assets for the current year and the prior years.

E. Income Statement or Statement of Activities and Changes in Net Assets or Fund Balances for Current Year and Prior Years

Provide the requested information in relation to the following unless otherwise specified:

  1. the entity identified as the applicant in Item 5 of the application;
  2. the financials of the applicant entity itself; and
  3. the applicant entity's financials that are dedicated and specific to the facility indicated in Item 1 of the application.

If the applicant has revenues or expenses covering multiple facilities, enter only the pro rata portion dedicated and specific to the facility indicated in Item 1 of the application.

Income Statement is defined as a statement that summarizes a business's revenues and expenses for a specific cycle of operation; it reflects a business's operating performance by identifying the sources of income and expense that result in a final income or loss amount.

Note: An applicant who currently has a Probationary License is not required to report financial data for the prior years and should leave each line item blank.

Revenue

Routine Services — Private Pay — Enter the total amount the applicant earned for routine care and services to private pay residents (individuals who pay for care through personal means, including personal insurance) for the current year and the prior years. If the applicant did not earn any payment from private pay sources during the current year or the prior years, enter 0.

Routine Services — Medicare — Enter the total amount the applicant earned for routine care and services to residents who received Medicare benefits for the current year and the prior years. If the applicant did not earn any payment from Medicare sources during the current year or the prior years, enter 0.

Routine Services — Medicaid — Enter the total amount the applicant earned for routine care and services to residents who received Medicaid benefits for the current year and the prior years. If the applicant did not earn any payment from Medicaid sources during the current year or the prior years, enter 0.

Routine Services — Other — Enter the total amount the applicant earned for routine care and services to residents with payment sources other than private pay, Medicare, and Medicaid for the current year and the prior years. If the applicant did not earn any monies from sources other than private pay, Medicare, and Medicaid during the current year or the prior years, enter 0.

Ancillary Services — Enter the total amount that the applicant earned for non-routine care and services (therapies, radiology, laboratory, etc.) for the current year and the prior years. If the applicant did not earn any monies for providing ancillary services during the current year or the prior years, enter 0.

Interest Income — Enter the facility operation-related amount of interest income the applicant earned from cash deposits in financial institution(s), loan(s) made to borrower(s), or other sources of interest income for the current year and the prior years. If the applicant did not earn any interest income during the current year or the prior years, enter 0.

Other Income — Enter the facility operation-related amount of income that was generated from any activity outside of Routine Services, Ancillary Services, and Interest Income for the current year and the prior years. If the applicant did not generate other income during the current year or the prior years, enter 0.

Note: If the applicant is a nonprofit organization, enter the amount of revenue that was generated from grants, contributions, or any other source. If the applicant did not generate other income during the current year or the prior years, enter 0.

Total Revenue — Enter the total revenue by adding Routine Services - Private Pay, Routine Services - Medicare, Routine Services - Medicaid, Routine Services - Other, Ancillary Services, Interest Income and Other Income for the current year and the prior years.

Operating Expenses

Direct-care Staff Cost — Enter the total amount the applicant incurred for direct-care staff salaries/benefits for the current year and the prior years. If the applicant did not incur direct-care staff cost during the current year or prior years, enter 0.

Direct-care is defined as resident care provided by nursing personnel (registered nurses, licensed vocational nurses, medication aides, restorative aides, certified nurse aides, registered respiratory therapists, and certified respiratory therapy technicians) in order to carry out the physician's planned regimen of total resident care.

Other Resident Care Cost — Enter the total amount the applicant incurred for staff salaries/benefits, services, and supplies associated with resident care costs other than direct-care staff costs (social work, activity, therapy, medical director, medical record, medical equipment, radiology, pharmacy, laboratory, etc.) for the current year and the prior years. If the applicant did not incur any other resident care cost during the current year or prior years, enter 0.

Dietary Cost — Enter the total amount the applicant incurred for staff salaries/benefits, services, and supplies (perishable/non-perishable food, utensils, napkins, containers, etc.) associated with dietary services for the current year and the prior years. If the applicant did not incur any dietary cost during the current year or prior years, enter 0.

Facility and Operations Cost — Enter the total amount the applicant incurred for staff salaries/benefits, services, and supplies associated with daily facility operations, including mortgage interest (maintenance, laundry, housekeeping, waste disposal, facility operation-related equipment, mortgage/lease, utilities, taxes, bad debt, operation interest expense, etc.) for the current year and the prior years. If the applicant did not incur any facility and operations cost during the current year or prior years, enter 0.

Administrative Cost — Enter the total amount the applicant incurred for staff salaries/benefits, services, supplies, and fees associated with administrative functions (billing, management, clerical, general office, insurance, training, seminars, subscriptions, etc.) for the current year and the prior years. If the applicant did not incur any administrative cost during the current year or prior years, enter 0.

Payroll Taxes and Workers' Compensation — Enter the total amount the applicant incurred for payroll taxes and workers' compensation for the current year and the prior years. If the applicant did not incur any payroll taxes or workers' compensation during the current year or prior years, enter 0.

Payroll taxes are defined as the portion of taxes levied on employees' salaries or income of self-employed individuals, including Social Security taxes, state unemployment taxes, and federal unemployment taxes, that the applicant paid, excluding the amount the applicant forwards on behalf of the employee.

Workers' compensation is defined as payments made by the applicant to the Workers' Compensation Fund or other payments made for workers involved in specific job-related injuries.

Total Operating Expenses — Enter the total operating expenses by adding Direct-care Staff Cost, Other Resident Care Cost, Dietary Cost, Facility and Operations Cost, Administrative Cost, and Payroll Taxes and Workers' Compensation for the current year and the prior years.

Non-operating Expenses

Interest Expense and Penalties — Enter the total amount of non-operating interest and/or penalties that the applicant paid on any borrowed non-operating funds for the current year and the prior years. If the applicant did not pay any interest expense during the current year or prior years, enter 0.

Depreciation — Enter the depreciation cost for the current year and the prior years. If the applicant will not have any depreciation for the current year and the prior years, enter 0.

Amortization — Enter the amortization cost for the current year and the prior years. If the applicant will not have any amortization costs for the current year and the prior years, enter 0.

Other Non-Operating Expense — Enter the total amount of non-operating expenses from sources other than interest expense, depreciation, and amortization (litigation, claims, assessments, fire loss, etc.) that the applicant paid for the current year and the prior years. If the applicant did not incur other non-operating expenses during current year or prior years, enter 0.

Total Non-Operating Expenses — Enter the total non-operating expenses by adding Interest Expense, Depreciation, Amortization, and Other Non-Operating Expense for the current year and the prior years. If the applicant did not incur any non-operating expenses during the current year or prior years, enter 0.

Income Tax Expense — Enter the amount of federal government levy on the taxable income for the current year and prior years, if the entity identified as the applicant in Item 5 of the application is subject to such a levy. If the applicant is not subject to a federal government levy on taxable income, enter 0.

Total Expenses — Enter the total expenses by adding Total Operating Expenses, Total Non-operating Expenses, and Income Tax Expense for the current year and the prior years. If the applicant did not incur any expense during the current year or prior years, enter 0.

Net Income/Revenue (loss) — Enter the applicant's profit/revenue or loss by subtracting Total Expenses from Total Revenue for the current year and the prior years. If this figure represents a loss, or a greater amount of expenses than of revenue, place parentheses around it.

Item 12 — Local Fire Authority Approval

Approval of the local fire authority is required for probationary, initial, re-open, relocation, renewal, change of ownership and capacity increase applications. The fire authority may sign the application or submit signed, dated, written approval in any format which identifies the facility by name and address.

Note: An application may be submitted even though the fire authority has not provided written approval at the time the application is filed. However, the license will not be issued until the fire authority's approval is provided.

Item 13 — Alzheimer's Care

Respond to the question by checking Yes or No. If Yes, complete and submit Form 3641-A, Alzheimer's Disclosure Statement for Nursing Facilities. Request this form from the Complaint Intake Unit toll-free at 800-458-9858 or in Austin at 512-438-2633.

Item 14 — Affidavit for Application, Including Compliance History

The applicant or authorized representative must attest that the information included in the application, all accompanying documents, and related compliance history is true and correct, and that he/she has knowledge of the ownership and of the penalty and criminal history of each controlling party. If the individual signing this affidavit is a representative of the applicant, this individual must meet the definition of a controlling person in Chapter 242 of the Texas H&SC, §242.0021 and must have full possession of signatory rights. The application must be notarized and must include the notary's seal or stamp.

 

Attachment A: Required Documents by Type of Application (as shown in Item 3 of Form 3720-N)

Business Entity Type Ownership Disclosure
Initial License
  • Complete Form 3720-N application
  • Form 3641-A, if Item 13 of Form 3720-N is Yes
  • Copy of facility administrator's current NFA license or license renewal card
  • Copy of Fire Marshall approved inspection report
  • Copy of NPI confirmation letter
  • Copy of dated, written notice to local health authority of license application (contact DADS Information Services at 512-438-2633 for the name and address of the applicable local health authority)
  • Application Fee (see fee schedule in Item 4 of Form 3720-N Instructions)
  • Applicant's Business Entity Documents (see Attachment B: Required Documents List According to Business Entity Type)
  • Management Company Agreement (if applicable)
  • Management Company Certificate of Formation from the state where business was formed, if applicable
  • Management Company Certificate of Registration from the Texas Secretary of State, if not formed in Texas (gives authority to transact business in Texas)
  • Management Company Certificate of Account Status from the Texas Comptroller of Public Accounts, if applicable
  • All property documents (such as a lease, sublease, Assignment of Lease, Deed of Trust, Warranty Deed, etc.)
  • Facility floor plan with legible room numbers (on plain 8.5 x 11 paper; do not send blueprints)
  • Proposed Bed Configuration Form (Provider Letter 01-39)
  • Written notice from the applicant that facility meets architectural requirements and is ready for an on-site Life Safety Code (LSC) inspection
  • An applicant for an initial license can obtain an Expedited Life Safety Code (ELSC) inspection when DADS receives a completed application, all fees and required documents. To request an ELSC inspection, you must submit a written request informing DADS that the facility meets the architectural requirements and is ready for its ELSC inspection, and submit the required fee listed in the schedule. See Attachment D: Table of Expedited Life Safety Code and Physical Inspection Fees.
License Renewal
  • Preprinted 3720-N application
  • Application fee (see fee schedule in Item 4) Note: the renewal fee is non-refundable
  • Copy of NPI Confirmation
  • Copy of Fire Marshall approved inspection report
  • Copy of facility administrator's current NFA license or license renewal card. Note: If reporting a change of administrator with the renewal, also submit the $20 fee.
  • Applicant's Certificate of Account Status from the Texas Comptroller of Public Accounts
  • Form 3641-A if Item 13 (Alzheimer's question) on Form 3720-N is Yes
Relocation
  • Complete Items 1, 2, 3, 4, 5 (Page 2), 8, 12, 13 and 14 of Form 3720-N application
  • Application fee (see fee schedule in Item 4 of Form 3720-N)
  • Copy of Fire Marshall approved inspection report
  • Copy of facility administrator's current NFA license or license renewal card. Note: If reporting a change of administrator with the change of relocation, also submit the $20 fee.
  • Applicant's Certificate of Account Status from the Texas Comptroller of Public Accounts
  • Facility floor plan with legible room numbers (on plain 8.5 x 11 paper; do not sent blueprints)
  • Proposed Bed Configuration Form (Provider Letter 01-39)
License Capacity Increase
  • Complete Items 1, 3, 4, 5 (Page 2) and 14 of Form 3720-N application
  • Application fee (see fee schedule in Item 4 of Form 3720-N)
  • Current and Proposed Bed Configuration Form (Provider Letter 01-39)
  • Facility floor plan with legible room numbers (on plain 8.5 x 11 paper; do not send blueprints)
  • Copy of Fire Marshall approved inspection report
  • Copy of dated, written notice to local health authority of license capacity increase application (contact DADS Information Services at 512-438-2633 for the name and address of the applicable local health authority
  • Written notice from the applicant that facility meets architectural requirements and is ready for an on-site Life Safety Code (LSC) inspection
Change of Ownership (CHOW)
  • Complete Form 3720-N application
  • Application fee (see fee schedule in Item 4 of Form 3720-N Instructions)
  • Form 3641-A if Item 13 (Alzheimer's question) on Form 3720-N is Yes
  • Form 3604, Ownership Transfer Affidavit
  • Copy of facility administrator's current NFA license or license renewal card. Note: If reporting a change of administrator with the change of ownership, also submit the $20 fee.
  • Copy of Fire Marshall approved inspection report
  • Copy of NPI confirmation letter
  • Copy of dated, written notice to local health authority of the change of ownership (contact DADS Information Services at 512-438-2633 for the name and address of the applicable local health authority
  • Applicant's Business Entity Documents (see Attachment B: Required Documents List According to Business Entity Type)
  • Management Company Agreement (if applicable)
  • Management Company Certificate of Formation from the state where business was formed, if applicable
  • Management Company Certificate of Registration from Texas Secretary of State, if not formed in Texas (gives authority to transact business in Texas)
  • Management Company Certificate of Account Status from the Texas Comptroller of Public Accounts, if applicable
  • All property documents (such as a lease, sublease, Assignment of Lease, Deed of Trust, Warranty Deed, etc.)
  • Form 3695, Prospective Owner Intentions Regarding Medicare Certification
Change of Administrator (CHAD)
  • Complete Form 3722-N application (if not being reported with a renewal or CHOW application)
  • Application fee (see fee schedule in Item 4 of Form 3720-N, Instructions)
  • Copy of facility administrator's current NFA license or license renewal card.
Real Estate Change
  • Complete Items 1, 3, 5 (Page 2), 8 and 14 of Form 3720-N application
  • All property documents that evidence the real estate change such as a lease, sublease, Deed of Trust, etc.
Management Company If adding a new Management Company or changing the existing Management Company
  • Complete Items 1, 3, 5 (Page 2), 6, 9 and 14 of Form 3720-N application
  • Management Company Agreement
  • Management Company Certificate of Formation from the state where business was formed
  • Management Company Certificate of Registration from the Texas Secretary of State, if not formed in Texas (gives authority to transact business in Texas)
  • Management Company Certificate of Account Status from the Texas Comptroller of Public Accounts
Shares Transfer (49% or less) for Licensee
  • Complete Items 1, 3, 5, 7, 9 and 14 of Form 3720-N application
  • A copy of the front and back of the shares certificates (for corporations only)
  • A copy of the meeting notes approving or authorizing the shares transfer
Re-open Current Licensee and license has NOT expired
  • Complete Form 3720-N application
  • Form 3641-A if Item 13 (Alzheimer's question) on Form 3720-N is Yes
  • Copy of facility administrator's current NFA license or license renewal card Note: If reporting a change of administrator for a re-open, also submit the $20 fee
  • Copy of Fire Marshall approved inspection report
  • Copy of NPI confirmation letter
  • Copy of dated, written notice to local health authority of the intent to re-open (contact DADS Information Services at 512-438-2633 for the name and address of the applicable local health authority
  • Application fee (see fee schedule in Item 4 of Form 3720-N, Instructions)
  • Management Company Agreement (if applicable)
  • Management Company Certificate of Formation from the state where business was formed, if applicable
  • Management Company Certificate of Registration from Texas Secretary of State, if formed outside of Texas (gives authority to transact business in Texas)
  • Management Company Certificate of Account Status from the Texas Comptroller of Public Accounts, if applicable
  • All property documents (such as a lease, sublease, Assignment of Lease, Deed of Trust, Warranty Deed, etc.)
  • Facility floor plan with legible room numbers (on plain 8.5 x 11 paper; do not send blueprints)
  • Proposed Bed Configuration Form (Provider Letter 01-39)
  • Written notice from the applicant that facility meets architectural requirements and is ready for an on-site Life Safety Code (LSC) inspection
Other Updates On Form 3720-N, if the update relates to:
  • Item 1, 2, 4 or 5, complete Items 1, 2, 3, 4, 5, 9 and 14
  • Item 6, complete Items 1, 2, 3, 5 (Page 2), 6, 9 and 14
  • Item 7, complete Items 1, 2, 3, 5 (Page 2), 7, 9 and 14
  • A licensee's business entity name changes, submit a copy of the Certificate of Amendment and the Articles of Amendment filed with the Texas Secretary of State
  • A Doing Business As (DBA) name change (also known as a facility name change), submit a copy of the Certificate of Assumed Business Name from the Texas Secretary of State. For a licensee that is a government authority or hospital district/authority, submit the Assumed Name Certificate from the county where the business is maintained.
Medicare and/or Medicaid Bed Changes
  • Complete Items 1, 3, 4, 5 (Page 2) and 14 of Form 3720-N
  • Current and Proposed Bed Configuration Form (Provider Letter 01-39)
  • Facility floor plan with legible room numbers (on plain 8.5 x 11 paper; do not send blueprints)

 

Attachment B: Required Documents List According to Business Entity Type

Business Entity Type Required Documents
Sole Proprietorship
  • IRS letter issuing Taxpayer Identification Number (Form CP-575) (if the sole proprietor is not using the SSN as the taxpayer identification number)
  • Assumed Name Certificate from the county where business is maintained
For-profit Corporation
  • Certificate of Formation from the state where the business was formed
  • Certificate of Registration from the Texas Secretary of State if not formed in Texas (gives authority to transact business in Texas)
  • Articles and/or By-laws
  • Any Certificate of Amendment filed to the original Certificate of Formation
  • Certificate of Account Status from the Texas Comptroller of Public Accounts
  • Certificate of Assumed Business Name from the Texas Secretary of State
  • IRS letter issuing Taxpayer Identification Number (Form CP-575 or 147-C)
Non-profit Organization Non-profit Organization (includes Non-profit Corporations, Non-profit Limited Liability Companies, and Non-profit Unincorporated Associations)
  • Certificate of Formation from the state where the business was formed
  • Certificate of Registration from the Texas Secretary of State if not formed in Texas (gives authority to transact business in Texas)
  • Articles and/or By-laws and/or Company Agreement
  • Any Certificate of Amendment filed to the original Certificate of Formation
  • Certificate of Account Status or Certificate of Exemption from the Texas Comptroller of Public Accounts
  • Certificate of Assumed Business Name from the Texas Secretary of State
  • IRS letter issuing Taxpayer Identification Number (Form CP-575 or 147-C)
Limited Liability Company
  • Certificate of Formation from the state where the business was formed
  • Certificate of Registration from the Texas Secretary of State if not formed in Texas (gives authority to transact business in Texas)
  • Company Agreement
  • Any Certificate of Amendment filed to the original Certificate of Formation
  • Certificate of Account Status from the Texas Comptroller of Public Accounts
  • Certificate of Assumed Business Name from the Texas Secretary of State
  • IRS letter issuing Taxpayer Identification Number (Form CP-575 or 147-C)
General Partnership
  • General Partnership Agreement (if none, a written statement to that effect is required)
  • Certificate of Account Status from the Texas Comptroller of Public Accounts
  • Assumed Name Certificate from county where business is maintained
  • IRS letter issuing Taxpayer Identification Number (Form CP-575 or 147-C)
General partnership registered as a limited liability partnership
  • Registration of a Limited Liability Partnership from the Texas Secretary of State
  • General Partnership Agreement (if there is none, a written statement to that effect is required)
  • Certificate of Account Status from the Texas Comptroller of Public Accounts
  • Assumed Name Certificate from county where business is maintained
  • IRS letter issuing Taxpayer Identification Number (Form CP-575 or 147-C)
Limited Partnership
  • Certificate of Formation from the state where business was formed
  • Certificate of Registration from the Texas Secretary of State if not formed in Texas (for authority to transact business in Texas)
  • Any Certificate of Amendment to the original Certificate of Formation
  • Limited Partnership Agreement
  • Certificate of Account Status from the Texas Comptroller of Public Accounts
  • Certificate of Assumed Business Name from the Texas Secretary of State
  • IRS letter issuing Taxpayer Identification Number (Form CP-575 or 147-C)
Limited partnership registered as a limited liability partnership
  • Registration of a Limited Liability Partnership from the Texas Secretary of State
  • Certificate of Formation from the state where business was formed
  • Certificate of Registration if not formed in Texas (gives authority to transact business in Texas)
  • Certificate of Account Status from the Texas Comptroller of Public Accounts
  • Any Certificate of Amendment filed to the original charter Certificate of Formation
  • Limited Partnership Agreement
  • Certificate of Assumed Business Name from the Texas Secretary of State
  • IRS letter issuing Taxpayer Identification Number (Form CP-575 or 147-C)
Trust, Living Trust or Estate
  • Will and/or Letters
  • Testamentary and/or Trust Agreement
  • Assumed Name Certificate from county where business is maintained
  • IRS letter issuing Taxpayer Identification Number (Form CP-575 or 147-C)
Other, specify Governmental Entity Type Federal, State, County, or City Governmental Authority or Hospital District/Authority
  • Documents that authorized the formation of, and established the existence of the Governmental Authority or Hospital District/Hospital Authority (obtain from relevant source, such as: city council, county commissioners’ court, or state/federal legislative branch of government)
  • By-laws or regulations of the applicable entity (Governmental Authority, Hospital District Authority, etc.), if by-laws or regulations exist
  • Assumed Name Certificate from county where business is maintained
  • IRS letter issuing Taxpayer Identification Number (Form CP-575 or 147-C)

 

Attachment C: Ownership and Controlling Person Information According to Business Entity Type

Note: Be sure to indicate titles.

Business Entity Type Ownership Disclosure
Sole Proprietorship
  • The sole proprietor
For-profit Corporation
  • All shareholders owning 5% or more (Percentages must total 100%; if percentages disclosed do not total 100%, answer questions at bottom of page in Items 5, 6 and 7 of Form 3720-N application)
  • President
  • Secretary
  • Treasurer
  • All officers
  • All directors
  • All executive trustees and/or managing employees

For for-profit corporations with shareholders that own less than 5%, disclose officers, directors, executive trustees, and/or managing employees.

Non-profit Organization
  • President
  • Secretary
  • Treasurer
  • All officers
  • All directors
  • All board members and/or board trustees
Limited Liability Company
  • All members and managers. (Percentages must total 100%. If there are membership units that are unassigned, include a note in the last block of the disclosure page that indicates the remaining membership units are unassigned.)
  • All officers
General Partnership
  • All partners (percentages must total 100%)
Limited Partnership
  • The general partner(s)
  • All limited partners
Retirement Systems, Investment Fund/Company
  • Fund Manager or Fund Advisor
  • Securities Exchange Commission identifying the company as an Investment Fund/Company
Trust, Living Trust
  • All trustees
Estate
  • Executor
Federal, State, County, or City Governmental Authority or Hospital District/Authority
  • All commissioners
  • All associate or deputy commissioners
 

 

Attachment D: Table of Expedited Life Safety Code and Physical Inspection Fees

  New Construction Additions/Remodel Alzheimer's Certification
Single Story $30 per bed,
$3,600 minimum
3% of construction cost
Minimum: $1,500, plus $30 per bed
Maximum: $3,000, plus $30 per bed
$850, plus $36 per bed
Multiple Story $36 per bed,
$4,500 minimum
3% of construction cost
Minimum: $1,500, plus $36 per bed
Maximum: $3,000, plus $36 per bed
$850, plus $36 per bed

 

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