Get Form 5871 2020-2025
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How to fill out the Form 5871 online
Filling out Form 5871 is a vital step for applicants and providers in Texas. This guide will provide you with comprehensive, step-by-step instructions to help you complete the form accurately and efficiently online.
Follow the steps to complete the Form 5871 online.
- Press the ‘Get Form’ button to access the form and open it in your editor.
- In Section 1, enter the legal name of the disclosing entity and any applicable doing business as (d/b/a) name. Fill in the contact person's name, title, area code, telephone number, fax number, and email address.
- Indicate the business entity type by selecting one from the provided options such as sole proprietor, for-profit corporation, or non-profit corporation. Provide the Taxpayer Identification Number (EIN or SSN) and the geographic information as required.
- In Section 2, disclose ownership and control interest information. Input first and last names, social security numbers, dates of birth, positions held, and physical addresses for individuals with ownership interests.
- For for-profit corporations, confirm ownership interest disclosure. Answer whether 100% ownership has been disclosed and whether remaining shareholders own less than 5%. Provide necessary disclosures if required.
- Proceed to Section 3 and detail any other ownership and control interests. Address questions about ownership interests in mortgage obligations or subcontractors, providing the legally required information for each.
- Complete Section 4 by answering general disclosure questions regarding any criminal offenses, sanctions, debts, or licensing issues for individuals or business entities identified in previous sections.
- In Section 5, certify that the information provided is accurate. Type the name of the owner or authorized representative, date, and title to complete the form.
- Once all sections are filled out, save your changes. You can download, print, or share the completed form as needed.
Complete your Form 5871 online today to ensure timely processing.
Related links form
The PO Box address for Medicaid in Texas may vary depending on the specific program or service you are using. Generally, documentation and inquiries should be directed to the Health and Human Services Commission (HHSC) at their designated PO Box in Austin, Texas. It's essential to verify the exact address for your specific needs to ensure your submissions reach the correct department promptly. For more details, individuals may refer to resources related to Form 5871 for accurate information.
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