Effective Date: 
7/2018

Documents

Instructions

Updated: 7/2018

 

  • Procedure
    • Transmittal
  • General Instructions
  • Detailed Instructions
  • Item 1 — Facility Information
  • Item 2 — Type of Application
    • Renewal
  • Item 3 — Number of Beds
    • Fee Schedule
  • Item 4 — Facility Administrator/Manager/Director
  • Item 5 — Applicant Information
    • Applicant Contact Person Information
    • Applicant Ownership and Controlling Person Information
    • Applicant Ownership and Controlling Person Information: Next Level(s)
  • Item 6 — Other Controlling Entity/Person Information
    • Other Controlling Entity/Person Contact Person Information
    • Other Controlling Entity Ownership and Controlling Person Information
    • Other Controlling Entity Ownership and Controlling Person Information: Next Level(s)
  • Item 7 — Real Estate Information
  • Item 8 — Disclosure of Facility/Agency Association
    • General Disclosure Questions
    • Five-Year Disclosure Questions
  • Item 9 — Local Fire Authority Approval
  • Item 10 — Affidavit for Application, including Compliance History
  • Attachment B: Ownership Disclosure According to Business Entity Type

Procedure

Complete this form to renew a license (a pre-printed application for renewal will be mailed to your office 120 days before expiration date of the license).

Retain a copy of the application and all supporting documents submitted to HHSC for your records.

Transmittal

Mail all applications with required documents and fees to:

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

Include the appropriate license fee and mail to the address above.

If sending applications and required documents without payment, send to:

Texas Health and Human Services Commission
Licensing and Credentialing (E-330)
P.O. Box 149030
Austin, TX 78714-9030

For overnight delivery only if no payment is included:

Texas Health and Human Services Commission
Licensing and Credentialing (E-330)
701 West 51st St.
Austin, TX 78751

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)
    Exception: Board members of government entities
  • title, position or relationship to owning entity
  • percentage of ownership
  • address

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

  • name of organization
  • tax identification number
  • percentage of ownership
  • address

DETAILED INSTRUCTIONS

Item 1. Facility Information

Facility Name — Enter the name of the facility. Do not abbreviate.

Facility ID No. — Enter the facility identification number (leave blank if not yet issued).

Physical Address — Enter the address of the facility, including street, city, state and ZIP Code, where the facility is physically located.

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

Facility Area Code and Telephone No. — Enter the area code and telephone number at the facility location.

Facility Area Code and Fax No. — Enter the facility's area code and fax number.

Facility Email Address — Enter the facility's email address.

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

National Provider Identifier No. — Enter the facility's National Provider Identifier Number (NPI) assigned by the Centers for Medicare & Medicaid Services (CMS), if applicable.

Item 2. Type of Application

  • Complete all parts of this application.
  • Enclose non-refundable license fee in the amount of $100.
  • Submit required fire marshal approval 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 the fire marshal approval documents are provided.

Renewal — Check this box to renew a current license. A preprinted renewal form and instructions are mailed to the owner 120 days before the license expires. Renewal applications must be submitted 45 days before the license expiration date. An applicant that submits an application for renewal later than the 45th day before the expiration of the license must pay a late fee of an amount equal to one half of the basic license fee. If you do not receive a preprinted renewal application or have a question about renewing your license, please call Regulatory Services, Licensing and Credentialing, at 512-438-2630. HHSC accepts and processes only preprinted renewal applications.

  • If the information on the preprinted renewal is not correct, line through the incorrect information and record the change/update on the preprinted renewal application. Sign, date and notarize the completed application and return it to this office.
  • Submit a non-refundable license renewal fee.
  • Retain a copy of the completed renewal application for your records.

Item 3. Number of Beds

Fee Schedule

Type of Application Licensed Capacity: 4 Fee Enclosed $
Renewal   $100
  • The license fee for a two-year license is $100, effective Sept. 1, 2008.

Item 4. Facility Administrator/Manager/Director

Enter the name and Social Security number of the administrator/manager/director.

Item 5. 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.

Taxpayer 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, ZIP/Postal Code and Country — Self-explanatory.

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

Area Code and Telephone No. — Self-explanatory.

Area Code and Fax No. — Self-explanatory.

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

Business Entity Type — Check the applicable Business Entity Type.

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

Applicant Contact Person 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 5 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. If no email address, leave blank.

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.).

Applicant Ownership and Controlling Person Information

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

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

Legal Name of Applicant (corporation, LLC, partnership, sole proprietorship, etc.) — Enter the legal name of the business or governmental entity applying for the license 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.

Taxpayer 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). HHSC requests voluntary disclosure of the Social Security number in order to conduct the evaluation specified in Health and Safety Code, §247.023 and §252.032; Texas Administrative Code, Title 40, Chapter 90, §90.11, Chapter 92, §92.11, and Chapter 98, §98.11; and Human Resources Code, §103.007. If the individual chooses not to furnish his or her Social Security number, the application process may be delayed and additional information may be requested to validate the individual's identity.

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

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 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 facility.

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

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

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

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

Legal Name of Business Entity disclosed on this page (Corporation, LLC, Partnership, Sole Proprietorship, etc.) — Enter the legal name of the business entity listed in the previous section of Item 5.

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.

Taxpayer 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). HHSC requests voluntary disclosure of the Social Security number in order to conduct the evaluation specified in Health and Safety Code, §247.023 and §252.032; Texas Administrative Code, Title 40, Chapter 90, §90.11, Chapter 92, §92.11, and Chapter 98, §98.11; and Human Resources Code, §103.007. If the individual chooses not to furnish his or her Social Security number, the application process may be delayed, and additional information may be requested to validate the individual's identity.

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

Item 6 — Other Controlling Entity/Person Information

Provide the information requested for any business entity or individual not disclosed in Item 5 and 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 facility funds or any other aspect of facility operation meets the definition of controlling person.)

If additional entries are required for disclosure of all owners and controlling entities/persons, copy this section of Item 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 (if other than individual) — Enter the name of the controlling entity.

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

Taxpayer Identification No. — For a business entity, enter the nine-digit taxpayer identification number of the legal business entity assigned by the 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). HHSC requests voluntary disclosure of the Social Security number in order to conduct the evaluation specified in Health and Safety Code, §247.023 and §252.032; Texas Administrative Code, Title 40, Chapter 90, §90.11, Chapter 92, §92.11, and Chapter 98, §98.11; and Human Resources Code, §103.007. If the individual chooses not to furnish his or her Social Security number, the application process may be delayed, and additional information may be requested to validate the individual's identity.

State/Country of Residence — If the individual being disclosed is a resident of the United States, 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 – Street or P. O. Box (if different from physical address), 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 facility, professional consultant or consulting company, spouse, etc.).

Other Controlling Entity/Person Contact Person Information

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

Area Code and Telephone No. — Self-explanatory.

Area Code and Fax No. — Self-explanatory.

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

Title or Relationship to 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

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 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 Other Controlling Entity (corporation, LLC, partnership, sole proprietorship, etc.) — Enter the legal name of the business entity that meets the definition of controlling person. (This field will be entered for you.)

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.

Taxpayer 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). HHSC requests voluntary disclosure of the Social Security number in order to conduct the evaluation specified in Health and Safety Code, §247.023 and §252.032; Texas Administrative Code, Title 40, Chapter 90, §90.11, Chapter 92, §92.11, and Chapter 98, §98.11; and Human Resources Code, §103.007. If the individual chooses not to furnish his or her Social Security number, the application process may be delayed, and additional information may be requested to validate the individual's identity.

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

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

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

Mailing Address – Street or P.O. Box (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 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 facility.

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

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 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 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.

Taxpayer 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). HHSC requests voluntary disclosure of the Social Security number in order to conduct the evaluation specified in Health and Safety Code, §247.023 and §252.032; Texas Administrative Code, Title 40, Chapter 90, §90.11, Chapter 92, §92.11, and Chapter 98, §98.11; and Human Resources Code, §103.007. If the individual chooses not to furnish his or her Social Security number, the application process may be delayed, and additional information may be requested to validate the individual's identity.

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

Item 7 — 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 7 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 facility is located and other properties permanently attached to the land, such as buildings in which the facility 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 5, check Yes. If the real property is owned partially by the entity identified as the applicant in Item 5, or by an individual or entity other than the applicant, check No.

To own the real property, as that term is used in Item 7, 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 — Enter the legal name of the business entity(ies) or individual(s) that owns the real property.

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

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

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

Area Code and Telephone No. — Self-explanatory.

Area Code and Fax No. — Self-explanatory.

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

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

If Yes, 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 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 from the business or individual 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 from the business or individual identified in Section D, F, H or J — Enter the legal name of the business entity or individual that holds assignment of the lease or other entitlement to occupy the real property from the business or individual identified in Section D, F, H or J.

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

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

If Yes, 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 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 8. Disclosure of Facility/Agency Association

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

Include facilities/agencies located in Texas and any other state. If the individual(s)/entity(ies) listed in Item 5 or 6 are associated with no facility(ies)/agency(ies), other than the facility 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.

Long-term care facility/agency includes adult day care facilities, assisted living facilities, durable medical equipment companies, home health agencies, hospices, facilities serving people with mental retardation or related conditions 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 10.

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

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

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

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

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

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

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

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

General Disclosure Questions

Complete this section for all individuals and entities listed on the application in Items 5 or 6. General Disclosure Questions A through D have no time-frame limitations. If answering any question affirmatively in relation to a long-term care facility or agency, provide the requested information for the time period during which the individual or entity is, or was, a controlling person, as indicated in Item 8, Disclosure of Facility/Agency 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 long-term care facility or agency.
  • Provide the incident details as specified below, if applicable for each question.
  • List all individuals/entities who were associated with the facility or agency during the time period in question, as indicated in Item 10, Disclosure of Facility/Agency Association.

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

A.

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

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

Conviction — Enter the crime 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.

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 (begin and end dates) of the exclusion or debarment.

C.

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

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

Reason — Enter the reason for the exclusion or disqualification, such as use of emergency assistance funds in a facility for which a trustee is appointed for purposes other than to pay the expenses of the trustee; substantial failure to comply with Health and Safety Code, Chapter 247 or Chapter 252, Human Resources Code, Chapter 103, or Texas Administrative Code, Chapter 90, Chapter 92 or Chapter 98; Medicaid fraud, conviction of injury to a person who is elderly, etc.

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

D.

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

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

Nature/Type of Court Order — Enter the nature/type of the court order (for example, temporary restraining order, temporary injunction, permanent injunction, etc.).

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

Terms of Court Order — Enter the terms specified in the court order, such as the begin and end dates for which a restraining order was in effect.

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

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

Five-Year Disclosure Questions

Complete this section for all individuals and entities listed on the application in Items 5 or 6. 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 long-term care facility or agency, provide the requested information for the time period during which the individual or entity is or was a controlling person as indicated in Item 8, Disclosure of Facility/Agency Association.

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

E.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

F.

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

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

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

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

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

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

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

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

G.

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

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

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

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

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

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

H.

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

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

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

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

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 or penalty owed.

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

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

I.

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

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

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

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

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

Amount Owed — Enter the amount of the fee owed.

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

J.

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

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

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

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

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

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

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

K.

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

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

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

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

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

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

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

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

Amount Unpaid — Enter the amount unpaid.

L.

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

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

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

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

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

M.

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

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

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

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

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

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

N.

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

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

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

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

Date Trustee/Manager Placed in the Facility — Enter the date the trustee/manager assumed operation of the facility as specified by the court order.

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

O.

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

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

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

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

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

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

P.

Owned, operated managed or otherwise been involved in ... — 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.

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

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

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

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

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

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

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

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

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

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

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 date of the regulatory visit that resulted in the recommendation for directed plan of correction.

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

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

Date of Certification/Contract Termination — Enter the date specified by the regulatory authority on which the facility's certification/contract was terminated.

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

6. Downgrade of the Status of a Facility License: Effective Date — Enter the date specified by the regulatory authority on which the facility'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 end date of the regulatory visit, if known, that resulted in the administrative penalty and the date that the administrative penalty was imposed. If the penalty was not related to a visit, enter the imposition date only.

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

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

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

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

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

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

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

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

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

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

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

Ownership and Control Interest Disclosure

Check the box for Yes, Exempt or N/A Sole Proprietor to signify the Legal Entity name described in Item 5 is in good standing with the Texas Comptroller’s Franchise Tax Requirements.

Item 9. Local Fire Authority Approval

Approval of the local fire authority is required for renewal license applications. The fire authority may sign the application or you may submit a signed and dated written approval in any format that identifies the facility by name and/or address. Do not delay submitting the application because you are awaiting fire marshal approval.

Item 10. 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 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 Applications and Issuance Unit at 512-438-2630 and ask to speak to a licensing specialist or enrollment specialist. To facilitate the licensing process, each application is assigned to a licensing specialist or enrollment specialist upon receipt. You will be informed of the specialist's name and telephone number for your facility's application. Any questions or correspondence relating to your application should be directed to this individual.

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 corporations with shareholders that own less than 5%, disclose officers, directors, executive trustees and/or managing employees
Non-profit Organization
  • President
  • Secretary
  • Treasurer
  • All officers
  • All directors
  • All board members and/or board trustees
Limited Liability Company
  • All members and managers. (Percentages must total 100%. If there are membership units that are unassigned, include a note in the last block of the disclosure page that indicates the remaining membership units are unassigned.)
  • All officers
General Partnership
  • All partners (percentages must total 100%)
Limited Partnership
  • 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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