Effective Date: 
5/2018

Documents

Instructions

Updated: 9/2014

 

Procedure

Complete this form to:

  • Apply for a license
    • to apply for an initial license
    • following the revocation or denial of a license
    • following the withdrawal of a license
    • because of a lapse in a center's license
  • Renew a license
  • Apply as a new business operator because of a change of ownership
  • Report a change of administrator or financial officer
  • Increase a center's licensed capacity in conjunction with a renewal or change of ownership
  • Report new or change in management company or update management company related information
  • Report share transfers
  • Apply for a relocation of the center (mark relocation and initial application)
  • Report a change in the real estate owner and/or lien holder, or other encumbrance changes
  • Report updates (that do not require the issuance of a new license) of previously reported information that will or has changed throughout the application, such as principals and controlling persons

Retain a copy of the application and all supporting documents submitted to the Texas Health and Human Services Commission (HHSC) for your records.

Transmittal

Mail all applications with required documents and fees to:

Texas Health and Human Services Commission
Accounts Receivable, Mail Code E-411
P.O. Box 149030
Austin, TX 78714-9030

For overnight delivery only, send applications with required documents and fees to:

Texas Health and Human Services Commission
Accounts Receivable, Mail Code E-411
701 West 51st St.
Austin, TX 78751

Include the appropriate license fee for all applications and mail to the address above. (Refer to the fee schedule on Item 2 of the application for the specific fee amount based on the type of application checked in Item 2).

General Instructions

When the name of an individual is requested, provide the following information:

  • Full name
  • Date of birth
  • Driver license number
  • Social Security number (United States) or Social Insurance number (Canada)
  • Title, position or relationship to owning entity
  • Percentage of ownership
  • Address

When information about an organization is requested, provide the following:

  • Name of organization
  • Employer identification number
  • Percentage of ownership
  • Address

Detailed Instructions

Item 1. Center Information

Center Name — Enter the name of the center. Do not abbreviate.

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

Physical Address - Street, City, State, ZIP Code — Enter the address of the center, including street, city, state and ZIP code where the center is physically located.

County — Enter the county in which the center is located.

Center Area Code and Telephone No. — Enter the area code and telephone number at the center location.

Center Area Code and Fax No. — Enter the center's area code and fax number.

Center Email Address — Enter the center's email address.

Mailing Address - Street or P.O. Box (if different from physical address), City, State, ZIP Code — The center license and other center correspondence will be mailed to this address.

Center Operating Hours — Enter the center’s operating hours.

Requested Licensed Capacity — Enter the total licensed capacity the center is applying for.

Item 2. Type of Application

Initial — Check this box to apply for a license to operate a new center; to apply for a license following the revocation, denial or withdrawal of a license; or to apply for a license due to a lapse in a center's license.

  • Provide a copy of the Pre-Licensure Computer-Based Training Certificate signed and dated. Complete one certificate each for the Administrator and the Alternate Administrator.   Retain copies for your records.
  • Complete all parts of this application (Form 3720-P).
  • Enclose the non-refundable license fee. Refer to Item 2, Fee Schedule.
  • Enclose a copy of your dated, written notice to the local health authority that you have applied for a license and that construction or modification has been or will be completed by a specific date.
  • Submit required documents. Note: An application may be submitted even though some documents are not available to the applicant (for example, fire marshal approval). However, the license will not be issued until all documents are provided.
  • Submit a letter of credit for $250,000, from a bank that is insured by the Federal Deposit Insurance Corporation (FDIC), to demonstrate an applicant’s financial viability.
  • Submit fire marshal approval.
  • Submit evidence that the applicant has the right to possession of the center (for example, deed or trust, lease agreement or appropriate legal document).
  • Attachment B of these instructions for required legal entity documents.
  • Submit a letter informing this office that the center meets the architectural requirements and is ready for its Life Safety Code inspection. The center must have Life Safety Code approval before a minor can be admitted.
  • Upon receipt of Life Safety Code architectural approval, notify your assigned enrollment technician/specialist that your center has passed its Life Safety Code inspection, you have admitted "x" number (must admit at least one, but no more than three) of minors and that your center is ready for its health inspection.

Relocation — Refer to instructions for Initial.

Licensed Capacity Increase/Decrease — Check this box to apply for an increase in the capacity of the center in conjunction with a renewal or change of ownership. If you are requesting a capacity increase only, submit Form 3716, Application to Increase Licensed Capacity of a Long-Term Care Facility.  

  • Complete all parts of this application.
  • Enclose the non-refundable capacity increase fee of $875.00.
  • Enclose a copy of your letter notifying the local health authority of your application for an increase in capacity.
  • Enclose a letter with the application that states the center meets architectural requirements.
  • Submit current fire marshal approval.

Renewal — Renewal applications must be submitted 60 days before the license expiration date. An applicant that submits an application for renewal after the 60th day before the expiration of the license must pay a late fee of $50 for each day after the 60th day, except that the total amount of a late fee may not exceed $500.00. If you have a question about renewing your license, call Regulatory Services, Licensing and Credentialing (Option 4), at 512-438-2630.

  • Submit a non-refundable license renewal fee (refer to Item 2 of these instructions for information related to fee amount required).
  • Submit required documents. Note: An application may be submitted even though some documents are not available to the applicant (for example, fire marshal approval). However, the license will not be issued until all documents are provided.
  • Enclose a fire marshal approval.
  • Retain a copy of the completed renewal application for your records.

Change of Ownership — Check this box to apply for a license as a new business operator/license holder due to a change of ownership (CHOW). Provide the effective date of the ownership change in the space provided.

  • Before the sale of the center, the license holder must notify HHSC that a CHOW is about to take place.
  • Provide a copy of the Pre-Licensure Computer-Based Training Certificate signed and dated. Retain a copy for your records.
  • Complete all parts of this application.
  • Enclose the non-refundable license fee. Refer to Item 2, Fee Schedule.
  • Form 3725, Licensure Change of Ownership Affidavit.
  • Enclose a copy of your letter notifying the local health authority of your application for a new license due to a CHOW.
  • Submit required documents. Note: An application may be submitted even though some documents are not available to the applicant (for example, fire marshal approval). However, the license will not be issued until all documents are provided:
    • Fire marshal approval;
    • Evidence that the applicant has the right to possession of the center (for example, deed or trust, lease agreement, appropriate legal document); and
    • Attachment B of these instructions for required legal entity documents.

Updates — Provide updates to previously provided information that will or has changed throughout the application, such as principals and controlling persons.

Change of Center Administrator or Financial Officer — Check this box to report a change of administrator or financial officer (not previously reported) in conjunction with a renewal or change of ownership.

  • Complete Items 1, 2, 3, 4, 5 and 11 of this application.
  • Provide the effective date of the administrator or financial officer change.

Change in Center Operating Hours — Check this box and provide the new hours and effective date.

Transfer of Ownership Interest — Check this box to supply information about the transfer of  stock/controlling/managing or governing interest at any level of the organizational structure. If the transfer involves the management company, note this in Item 2 of the application.

Other Updates — Check this box and provide other updates and the effective date.

Real Estate Change — Check this box if a real estate change and provide the effective date.

Management Company — Check this box if the center is managed by or proposed to be managed under a management agreement. Disclose information about the management company and its principals in ownership and control in Items 7, 8 and 10 on the application.

  • Supply a letter notifying this office about the commencement of the management company and the effective date, and provide a copy of the management company agreement.
  • Complete Items 1, 2, 4, 7, 10, and 11 of the application.

Fee Schedule and Fee Enclosed — Enter the total fee based on the fee schedule below.

Fee Schedule

Type of Application Prescribed Pediatric Extended Care Center License Fees

Initial

$1,750.00

Change of Ownership

$1,750.00

Relocation

$1,750.00

Renewal

$1,750.00

Late Renewal

$50 per day after renewal submission deadline, not to exceed $500.

Capacity Increase

 $875.00

 

Item 3. Center Administrator/Financial Officer

Complete All Sections of Item 3: Name of Administrator, Social Security No., Address, City, State, ZIP code and Name of Financial Officer, Social Security No., Address, City, State and ZIP Code.

Item 4. Applicant 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 as chartered, filed, registered or otherwise legally declared.

Note: For all applications except initial and CHOW, 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.

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

For an individual who has not been assigned a taxpayer identification number by the Internal Revenue Service, the Social Security number assigned by the Social Security Administration may be used as the taxpayer identification number. Individuals who do not wish to disclose their Social Security number must obtain a taxpayer identification number from the Internal Revenue Service prior to submission of the application.

Physical Address – Street, City, State/Province, ZIP/Postal Code and Country — Self-explanatory.

Mailing Address (if different from Physical Address) – Street or P. O. Box, City, State/Province, ZIP/Postal Code and Country — Enter the business entity’s (applicant) mailing address. Do not enter the center's mailing address in this box unless the business entity’s mailing address is also the center's mailing address.

Area Code and Telephone No. — Self-explanatory.

Area Code and Fax No. — Self-explanatory.

Email Address — Self-explanatory.

Business Entity Type — Check the applicable Business Entity Type and submit one copy of each document listed in Attachment A, Required Documents According to Business Entity Type.

If the applicant is a business entity, check the applicable box and follow the instructions for Business Entity Type.

Government Entity Type — If the applicant is a governmental entity, check the applicable box for Governmental Entity Type.

Applicant Contact Information

Last Name, First Name, Middle Initial, Jr., Sr., etc. — Enter the full name of the person who has authority to provide information pertaining to Item 6 on behalf of the applicant, both during the application process and throughout the licensure period.

Area Code and Telephone No. — Self-explanatory.

Area Code and Fax No. — Self-explanatory.

Email Address — Self-explanatory.

Title or Relationship to Applicant — Enter the contact person's professional or personal relationship to the applicant (examples: authorized representative, president, partner, manager, administrator, administrative assistant, spouse, etc.).

Item 5. Application Preparer — Check the box if the preparer is the same as the applicant contact.

Preparer Firm/Business Name — Enter the legal name of the business preparing the application.

Address (if different from Physical Address) – Street or P. O. Box, City, State, ZIP Code — Self-explanatory.

Preparer Name — Enter the name of the person associated with the Preparer Firm/Business Name who is preparing the application.

Preparer Title — Enter the title of the person.

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

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

Preparer Email Address — Self-explanatory.

Item 6. 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 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 Applicant (corporation, LLC, partnership, sole proprietorship, etc.) — Enter the legal name of the business or governmental entity applying for the license as chartered, filed, registered or otherwise legally declared.

Attachment B, Ownership Disclosure 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.

Employer Identification No. — For a business entity, enter the nine-digit taxpayer identification number of the legal business entity assigned by the Internal Revenue Service. (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 Social Security number (United States) or Social Insurance number (Canada).

State/Country of Residence — If the individual being disclosed is a resident of the United States, 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 business physical address.

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 being disclosed 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 being disclosed on this page) — Enter the date on which the individual/entity's association with the entity disclosed 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 center.

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

Based on the first level of 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 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 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.

Attachment B, Ownership Disclosure 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.

Employer Identification No. — For a business entity, enter the nine-digit taxpayer identification number of the legal business entity assigned by the Internal Revenue Service. (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 Social Security number (United States) or Social Insurance number (Canada).

State/Country of Residence — If the individual being disclosed is a resident of the United States, 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 (if different from physical address), City, State/Province, ZIP/Postal Code, Country — Enter the mailing address, if different from the physical address.

Title or Position Held (with the entity being disclosed on this page) — Enter the title or position this individual/entity holds with the entity disclosed on this page (examples: shareholder, president, secretary, treasurer, member, manager, general partner, limited partner, trustee, etc.).

Start Date of Association (with the entity being disclosed on this page) — Enter the date on which the individual/entity's association with the entity disclosed 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 center.

Item 7. Management Company Information

If the center 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.

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

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.

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.

Attachment B, Ownership Disclosure 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.

Employer Identification No. — For a business entity, enter the nine-digit taxpayer identification number of the legal business entity assigned by the Internal Revenue Service. (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 Social Security number (United States) or Social Insurance number (Canada).

State/Country of Residence — If the individual being disclosed is a resident of the United States, 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 (if different from Physical 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 being disclosed 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 being disclosed on this page) — Enter the date on which the individual/entity's association with the entity disclosed 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 center.

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

Based on the first level of management company 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 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 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.

Attachment B, Ownership Disclosure 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.

Employer Identification No. — For a business entity, enter the nine-digit taxpayer identification number of the legal business entity assigned by the Internal Revenue Service. (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 Social Security number (United States) or Social Insurance number (Canada).

State/Country of Residence — If the individual being disclosed is a resident of the United States, 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 (if different from physical 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 being disclosed on this page) — Enter the title or position this individual/entity holds with the entity disclosed on this page (examples: shareholder, president, secretary, treasurer, member, manager, general partner, limited partner, trustee, etc.).

Start Date of Association (with the entity being disclosed on this page) — Enter the date on which the individual/entity's association with the entity disclosed 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 center.

Item 8 — Other Controlling Entity/Person Information

Provide the information requested for any business entity or individual not disclosed in Items 6 and 7 of the application who meets the definition of controlling person, as defined in the General Instructions. (Example: A landlord who exerts influence over the disbursement of center funds or any other aspect of center 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 8 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.

Employer Identification No. — For a business entity, enter the nine-digit taxpayer identification number of the legal business entity assigned by the Internal Revenue Service. (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 Social Security number (United States) or Social Insurance number (Canada).

State/Country of Residence — If the individual being disclosed is a resident of the United States, 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/Postal Code — 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 (examples: landlord who exerts influence over the operation of the Center, 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.

Title or Relationship to the Other Controlling Entity/Person — Enter the contact person's professional or personal relationship to the other controlling entity/person (examples: authorized representative, president, partner, manager, administrator, administrative assistant, spouse, etc.).

Other Controlling Entity Ownership and Controlling Person Information (Continued)
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 8 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. Then disclose each entity and individual who is a controlling entity/person. See Attachment B, Ownership Disclosure 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.

Employer Identification No. — For a business entity, enter the nine-digit taxpayer identification number of the legal business entity assigned by the Internal Revenue Service. (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.

Social Security No. — For an individual, record his/her Social Security number (United States) or Social Insurance number (Canada).

State/Country of Residence — If the individual being disclosed is a resident of the United States, 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 (if different from Physical 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 being disclosed on this page) — Enter the title or position this individual/entity holds with the other controlling entity (examples: shareholder, president, secretary, treasurer, member, manager, general partner, limited partner, trustee, etc.).

Start Date of Association (with the entity being disclosed on this page) — Enter the date on which the individual/entity's association with the entity disclosed 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 center.

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

Based on the first level of ownership information in Item 8, complete the next level(s) of ownership and controlling person information. Complete this section for each business entity previously disclosed in Item 8 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 8 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 8.
Disclose each entity and individual with an ownership interest in the other controlling entity for each level of ownership according to the entity type. Then disclose each entity and individual who is a controlling entity/person for each level of ownership. See Attachment B, Ownership Disclosure 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.

Employer Identification No. — For a business entity, enter the nine-digit taxpayer identification number of the legal business entity assigned by the Internal Revenue Service. (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 Social Security number (United States) or Social Insurance number (Canada).

State/Country of Residence — If the individual being disclosed is a resident of the United States, 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 (if different from Physical 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 being disclosed on this page) — Enter the title or position this individual/entity holds with the entity disclosed on this page (examples: shareholder, president, secretary, treasurer, member, manager, general partner, limited partner, trustee, etc.).

Start Date of Association (with the entity being disclosed on this page) — Enter the date on which the individual/entity's association with the entity disclosed 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 center.

Item 9 — 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 9 of the application to use as an attachment for multiple entries.

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

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

A 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 4, check Yes. If the real property is owned partially by the entity identified as the applicant in Item 4, or by an individual or entity other than the applicant, check No.

To own the real property, as that term is used in Item 9, 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, provide 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, provide 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 where the center will be located— 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

Last Name, First Name, Middle Initial, Jr., Sr., etc. — Enter the full name of the real property owner's representative who can be contacted about the real estate information in this item.

Area Code and Telephone No. — Self-explanatory.

Area Code and Fax No. — Self-explanatory.

Email Address — Self-explanatory.

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

If Yes, provide 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.

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, provide 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.

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, provide 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.

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 used to operate the center 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, provide 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.

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(ies) 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. Provide 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, provide 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.

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 used to operate the center from the business entity(ies) or individual(s) 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, provide 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.

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 used to operate the center 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 10. Disclosure of Center/Agency/Facility Association

List all other centers, agencies or long-term care facilities that are not licensed by HHSC or are located outside of Texas for which an individual/entity listed in Item 6, 7 or 8 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 centers, agencies or long-term care facilities located in Texas and any other state. If the individual(s)/entity(ies) listed in Item 6, 7 or 8 are associated with no centers, agencies or long-term care facilities, other than the center in Item 1, no further entries are required. Provide the requested information for the five-year period up to and including the date of the application.

Center, Agency or Long-term Care Facility includes prescribed pediatric extended care centers, adult day care facilities, assisted living facilities, durable medical equipment companies, home health agencies, hospices, facilities serving individuals with an intellectual disability or a related condition, and nursing facilities.

The date of the application is defined as the date the applicant or the applicant's authorized representative signs the Affidavit for Application, Item 11.

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

Center/Agency/Facility Name — Enter the name of the center, agency or long-term care facility associated with the above individual(s)/entity(ies) listed in Item 6, 7 or 8; enter the name exactly as it appears on the filed Assumed Name Certificate.

Center/Agency Identification No. — For centers, agencies or long-term care facilities located in Texas, enter the center, agency or long-term care facility identification number issued by the state of Texas; if this number has not yet been issued by the state, enter the center, agency or long-term care facility license number. For out-of-state centers, agencies or long-term care facilities, enter the identification number issued by the applicable regulatory authority.

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

Physical Address – Street, City, State/Province, ZIP/Postal Code — Enter the address where the center, agency or long-term care facility is physically located.

Individual/Entity — Enter the names of individual(s) or business entity(ies) listed in Item 6, 7 or 8 who is, or was, a controlling person of the center, agency or long-term care facility.

Start Date of Association — Enter the date on which the individual/entity's association with the center, agency or long-term care facility began.

End Date of Association — Enter the date on which the individual/entity's association with the center, agency or long-term care facility ended. If the association is ongoing, leave this field blank.

Item 10. General Disclosure Questions
Complete this section for all individuals and entities listed on the application in Items 6, 7 or 8. General Disclosure Questions A through D have no time-frame limitations. If answering any question affirmatively in relation to a center, agency or long-term care facility, provide the requested information for the time period during which the individual or entity is or was a controlling person, as indicated in Item 10, Disclosure of Center/Agency/Facility Association.
Respond by checking Yes or No for each section, A through D. If Yes is answered for any question, provide the requested information.

  • Identify the center, agency or long-term care facility.
  • Provide the incident details as specified below, if applicable, for each question.
  • List all individuals/entities who were associated with the center, agency or long-term care facility during the time period in question, as indicated in Item 10, Disclosure of Center/Agency/Facility Association.  

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

A. Been convicted of a state of federal crime that carries a penalty of incarceration? — Check Yes or No.

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 for 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. Been excluded or debarred from participating in federal government programs? — Check Yes or No.

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. Been excluded or otherwise disqualified from holding a license in the state of Texas or any other state? — Check Yes or No.

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.

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

D. Been subject to orders from a court restraining or enjoining the individual or entity from operating a center, agency or facility? — Check Yes or No.

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 center, agency or long-term care facility 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 6, 7 or 8. 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. If answering any question affirmatively in relation to a center, agency or long-term care facility, provide the requested information for the time period during which the individual or entity is or was a controlling person as indicated in Item 10, Disclosure of Center/Agency/Facility Association.

  • Identify the center, agency or long-term care facility.
  • Provide the incident details as specified below, if applicable, for each question.
  • List all individuals/entities who were associated with the center, agency or long-term care facility during the time period in question, as indicated in Item 10, Disclosure of Center/Agency/Facility Association.  

E. Been held liable for civil damages by a court, or settled such a suit out of court . . .? — Check Yes or No.

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.

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

Center/Agency/Facility Identification No. — For centers, agencies or long-term care facilities located in Texas, enter the center, agency or long-term care facility identification number issued by the state of Texas. If this number has not yet been issued by the state, enter the center, agency or long-term care facility license number. For out-of-state centers, agencies or long-term care facilities, 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 center, agency or long-term care facility 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 Paid or Not paid box to indicate whether or not the center, agency or long-term care facility 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, center or agency or individual/entity did not pay the judgment or settlement, explain the reason for nonpayment.

Note: If the applicant answered Question A affirmatively for a center, agency or long-term care facility, the Individual/Entity field is calculated in the following manner: all individual(s)/entity(ies) associated with the given center, agency or long-term care facility with dates of association that include any of the dates in this section (Verdict Date, Judgment Date, Settlement Date).

F. Filed for bankruptcy protection (reorganization or liquidation) or been placed in receivership . . . ? — Check Yes or No.

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.

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

Center/Agency/Facility Identification No. — For centers, agencies or long-term care facilities located in Texas, enter the center, agency or long-term care facility identification number issued by the state of Texas. If this number has not yet been issued by the state, enter the center, agency or long-term care facility license number. For out-of-state centers, agencies or long-term care facilities, 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 center, agency or long-term care facility 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, center or 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. Ever owed any overdue payroll taxes, unemployment taxes, franchise taxes or workers’ compensation payments . . . ? — Check Yes or No.

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.

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

Center/Agency/Facility Identification No. — For centers, agencies or long-term care facilities located in Texas, enter the center, agency or long-term care facility identification number issued by the state of Texas. If this number has not yet been issued by the state, enter the center, agency or long-term care facility license number. For out-of-state centers, agencies or long-term care facilities, 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 who the tax or payment is/was owed.

Status — 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. Ever had fines or penalties assessed to any center, agency or long-term care facility related to payroll taxes, unemployment taxes or workers’ compensation . . . ? — Check Yes or No.

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.

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

Center/Agency/Facility Identification No. — For centers, agencies or long-term care facilities located in Texas, enter the center, agency or long-term care facility identification number issued by the state of Texas. If this number has not yet been issued by the state, enter the center, agency or long-term care facility license number. For out-of-state centers, agencies or long-term care facilities, 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. Owned, operated, managed or otherwise been involved in any center, agency or long-term care facility that has failed to pay any state licensing fees . . . ? — Check Yes or No.

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.

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

Center/Agency/Facility Identification No. — For centers, agencies or long-term care facilities located in Texas, enter the center, agency or long-term care facility identification number issued by the state of Texas. If this number has not yet been issued by the state, enter the center, agency or long-term care facility license number. For out-of-state centers, agencies or long-term care facilities, 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 Fee Not Paid — Enter the type of fee not paid by the facility, center or agency.

Amount Owed — Enter the amount of the fee owed.

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

J. Owned, operated, managed or otherwise been involved in any center, agency or long-term care facility that has failed to reimburse the Nursing and Convalescent Home Trust Fund following placement of a state trustee? — Check Yes or No.

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.

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

Center/Agency/Facility Identification No. — For centers, agencies or long-term care facilities located in Texas, enter the center, agency or long-term care facility identification number issued by the state of Texas. If this number has not yet been issued by the state, enter the center, agency or long-term care facility license number. For out-of-state centers, agencies or long-term care facilities, 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 Placed in the Center — Enter the date the trustee assumed operation of the Center 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. Had (or currently have) an unsatisfied judgment against them, either individually or in association with others, by a creditor or claimant . . . ? — Check Yes or No.

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.

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

Center/Agency/Facility Identification No. — For centers, agencies or long-term care facilities located in Texas, enter the center, agency or long-term care facility identification number issued by the state of Texas. If this number has not yet been issued by the state, enter the center, agency or long-term care facility license number. For out-of-state centers, agencies or long-term care facilities, 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, center or 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. Owned, operated, managed or otherwise been involved in any center, agency or long-term care facility that has been evicted from any property or space used as a center, agency or long-term care facility? — Check Yes or No.

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.

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

Center/Agency/Facility Identification No. — For centers, agencies or long-term care facilities located in Texas, enter the center, agency or long-term care facility identification number issued by the state of Texas. If this number has not yet been issued by the state, enter the center, agency or long-term care facility license number. For out-of-state centers, agencies or long-term care facilities, 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 long-term care facility, center or agency was evicted.

M. Owned, operated, managed or otherwise been involved in any center, agency or long-term care facility, hospital, boarding home, child care center, or drug or alcohol treatment center whose license(s) has been denied, revoked or suspended ? — Check Yes or No.

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.

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

Center/Agency/Facility Identification No. — For centers, agencies or long-term care facilities located in Texas, enter the center, agency or long-term care facility identification number issued by the state of Texas. If this number has not yet been issued by the state, enter the center, agency or long-term care facility license number. For out-of-state centers, agencies or long-term care facilities, 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. Owned, operated, managed or otherwise been involved in any center, agency or long-term care facility that has a state trustee or federal temporary manager placed? — Check Yes or No.

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.

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

Center/Agency/Facility Identification No. — For centers, agencies or long-term care facilities located in Texas, enter the center, agency or long-term care facility identification number issued by the state of Texas. If this number has not yet been issued by the state, enter the center, agency or long-term care facility license number. For out-of-state centers, agencies or long-term care facilities, 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 Center — Enter the date the trustee/manager assumed operation of the center, as specified by the court order.

Date Trustee/Manager Removed — Enter the date the trusteeship/management ended.

O. Owned, operated, managed or otherwise been involved in any center, agency or long-term care facility that 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? — Check Yes or No.

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.

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

Center/Agency/Facility Identification No. — For centers, agencies or long-term care facilities located in Texas, enter the center, agency or long-term care facility identification number issued by the state of Texas. If this number has not yet been issued by the state, enter the center, agency or long-term care facility license number. For out-of-state centers, agencies or long-term care facilities, 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 center, agency or long-term care facility 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 center, agency or long-term care facility surrendered the license or the center, agency or long-term care facility withdrew the appeal.

P. Owned, operated, managed or otherwise been involved in any center, agency or long-term care facility located outside of the state of Texas that has been subject to federal or state sanctions, penalties or enforcement actions? — Check Yes or No.

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 in-service training and temporary management; federal or state sanctions, penalties or enforcement actions do not include compliance letters.

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

Center/Agency/Facility Identification No. — For centers, agencies or long-term care facilities located in Texas, enter the center, agency or long-term care facility identification number issued by the state of Texas. If this number has not yet been issued by the state, enter the center, agency or long-term care facility license number. For out-of-state centers, agencies or long-term care facilities, 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 exit 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 exit date of the regulatory visit that resulted in the imposition of denial of payment for new admissions.
State 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 exit 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 exit 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 center'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 Center, Agency or Long-Term Care Facility License: Effective Date — Enter the date specified by the regulatory authority on which the center's license 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 exit 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.

Status — 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 exit date of the regulatory visit that resulted in the civil penalty

Status — 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 exit 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.

Status — 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 in-service 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 11. Affidavit for Application, Including Compliance History

The owner/applicant or authorized representative must attest that the information included in this application, including all accompanying forms and related compliance history, is true and correct. The application must be signed, dated, notarized and include the notary's signature and seal or stamp.

For Assistance

If, after reading these instructions for completing the application, you determine that you need further assistance, call the Regulatory Services Division, Licensing and Credentialing Section at 512-438-2630 option 4.  To facilitate the licensing process, each application is assigned to a licensing specialist upon receipt. You will be informed of the specialist's name and telephone number for your center's application. Any questions or correspondence relating to your application should be directed to this individual.

Attachment A: Required Documents List According to Business Entity Type

Business Entity Type Required Documents

Sole Proprietorship

  • Internal Revenue Service (IRS) letter issuing Taxpayer Identification Number (Form CP-575 or 147-C) (if the sole proprietor is not using the Social Security number as the taxpayer identification number)
  • Assumed Name Certificate from the county in which business premises are maintained

For-profit Corporation

  • Certificate of Formation from the Texas Secretary of State (SOS)
  • Certificate of Registration (if not formed in Texas for authority to transact business in Texas from the SOS)
  • Articles and/or by-laws
  • Any Certificate of Amendment, original Certificate of Formation, Certificate of Account Status from the Texas Comptroller of Public Accounts
  • Certificate of Assumed Business Name filed with the SOS
  • IRS letter issuing Taxpayer Identification Number (Form CP-575 or 147-C)

Non-profit Organization

Includes non-profit corporations, non-profit limited liability companies and non-profit unincorporated associations

  • Certificate of Formation from the SOS
  • Certificate of Registration (if not formed in Texas for authority to transact business in Texas from the SOS)
  • Articles and/or by-laws and/or company agreement
  • Any Certificate of Amendment 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 filed with the Texas SOS
  • IRS letter issuing Taxpayer Identification Number (Form CP-575 or 147-C)

Limited Liability Company

  • Certificate of Formation from the SOS
  • Certificate of Registration (if not formed in Texas for authority to transact business in Texas from the SOS)
  • Company Agreement
  • Any Certificate of Amendments to the original Certificate of Formation
  • Certificate of Account Status from the Texas Comptroller of Public Accounts
  • Certificate of Assumed Business Name filed with the Texas SOS
  • 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)
  • Assumed Name Certificate from county where business premises are 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 SOS
  • 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 in which business premises are maintained
  • IRS letter issuing Taxpayer Identification Number (Form CP-575 or 147-C)

Limited Partnership

  • Certificate of Formation from the SOS
  • Certificate of Registration (if not formed in Texas for authority to transact business in Texas from the SOS)
  • Certificate of Account Status from the Texas Comptroller of Public Accounts
  • Any Certificate of Amendment to the original Certificate of Formation
  • Limited Partnership Agreement
  • Certificate of Assumed Business Name from the SOS
  • 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
  • Certificate of Formation from the SOS
  • Certificate of Registration (if not formed in Texas for authority to transact business in Texas from the SOS)
  • Certificate of Account Status from the Texas Comptroller of Public Accounts
  • Any Certificate of Amendments to the original Certificate of Formation
  • Limited Partnership Agreement
  • Certificate of Assumed Business Name from the SOS
  • 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 in which business premises are maintained
  • IRS letter issuing Taxpayer Identification Number (Form CP-575 or 147-C)

Other, specify

Enter the legal entity type of the applicant if it is not one of the types specified on the application.

Governmental Entity Type

Check the applicable Governmental Entity Type and submit supporting legal documents as described below.

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 in which business premises are maintained
  • IRS letter issuing Taxpayer Identification Number (Form CP-575 or 147-C)

 

Attachment B: Ownership Disclosure 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 Items 6, 7 and 8 of this form)
  • President
  • Secretary
  • Treasurer
  • All officers
  • All directors
  • All executive trustees and/or managing employees
  • For all for-profit corporation with shareholders that own less than 5 percent, 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

  • 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

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