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Get AZ AHCCCD Disclosure Ownership Form 2012-2023

Sing entity in which a person with an ownership or control interest in the disclosing entity also has ownership or control interest of a t least 5% or more. Name Address TIN Percentage 1 of 3 Reset Disclosure of Ownership.doc DISCLOSURE OF OWNERSHIP/CONTROL AND CRIMINAL OFFENSES STATEMENTS Item III. Criminal Offenses (Reference-42CFR, Part 455.106 and SSA 1124) (a) List the name, title, SSN and address of each officer and/or individual who has ownership or control interest in the disclosing.

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