Get Disclosure Of Ownership And Control Statement - Dads State Tx

Filling out the Disclosure Of Ownership And Control Statement is an important step for applicants and providers looking to comply with regulations set forth by Texas Department of Aging and Disability Services. This guide will lead you through each section of the form, ensuring you provide all necessary information accurately and efficiently.

Follow the steps to complete the form online.

1. Click ‘Get Form’ button to access the form and open it in the provided editor.
2. In Section 1, fill in the disclosing entity information. This includes the legal name of the disclosing entity, any doing business as (d/b/a) names, and contact information for a designated contact person. Ensure that the email address and phone numbers are accurate for future communications.
3. Still in Section 1, select the business entity type from the provided options, such as sole proprietor, for-profit corporation, or nonprofit corporation. Make sure to include the taxpayer identification number (EIN or SSN) and the provider identifier number (NPI or API) if applicable.
4. In Section 2, provide detailed ownership and control interest information. You will need to fill out the names, social security numbers, dates of birth, titles, and physical addresses of individuals with ownership interests in the disclosing entity. Be meticulous to avoid errors in percent of ownership.
5. Continue in Section 2 to answer specific questions about whether full ownership has been disclosed. If not, indicate whether any remaining shareholders own less than 5%.
6. Move to Section 3, where you will need to identify any ownership interests in subcontractors. Answer the questions about ownership percentages and provide information about any individuals or entities with significant ownership interests.
7. In Section 4, respond to the general disclosure questions regarding any criminal convictions or exclusions related to state or federal programs, making sure to detail any applicable individuals or entities involved.
8. Finalize in Section 5 by certifying the accuracy of the information provided. You must sign the document and include the typed or printed name and title.
9. Once all sections are completed and verified for accuracy, save your changes. You may then choose to download, print, or share the form as necessary.

Complete your Disclosure Of Ownership And Control Statement online today to ensure your compliance and streamline your application process.