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What Is a Disclosure of Ownership Form

For example, if A holds 10% of the shares of a corporation that owns 80% of the shares of the disclosing corporation, A`s interest is equivalent to 8% indirect interest and must be reported. Conversely, if B holds 80% of the shares of a company that holds 5% of the shares of the disclosing company, B`s share corresponds to 4% of the indirect ownership of the disclosing company and does not need to be declared. Legal name of business unit – Enter the legal name of the business entity with a 5% or greater interest in a bond secured by the assets of the disclosing entity. The disclosing entity is required to fully disclose all levels of ownership of 5% or more and to fully disclose all entities and persons at each level of ownership, from the ownership of the disclosing entity to the ownership of each subsequent owner company. The share of 5 % or more may be a direct, indirect or a combination of direct and indirect ownership. Disclosure of the company`s percentage of the subcontractor`s ownership – Enter the percentage of the disclosing company`s stake in the subcontractor`s business unit. Form 5871 is completed and filed as a condition of approval or renewal of a Texas Medicaid application or contractual agreement between the disclosing company (applicant/provider) and the Health and Human Services Commission (HHSC) for a service program. Full and accurate disclosure of ownership and control rights is required. Failure to submit the requested information may result in the rejection of the Disclosing Company`s request to enroll in Texas Medicaid, participate in HHSC programs, or, if the Disclosing Company is already participating, terminate the Disclosing Company`s Texas Medicaid registration and HHSC agreement. The disclosing company is also required to fully disclose all persons who have a controlling interest at each level of ownership and all senior managers at each level of ownership. Select Yes or No to indicate whether 100% of the ownership shares have been disclosed in this section.

If not, check yes or no to indicate whether or not each of the remaining shareholders owns less than 5%. If not, identify other shareholders who hold a 5% or greater interest, or attach a statement explaining why these shareholders are not disclosed. The owner or an authorized representative of the disclosing body confirms that the information provided on the form and all appendices, if any, is true and complete. If the legal entity is not a sole proprietorship, the authorized representative must be named on an up-to-date Form 2031, Governing Authority Resolution – Business Organization, or Form 2031-G, Governing Authority Resolution – Government Entity, which is filed with HHSC. Based on the first level of ownership information in Section 2, complete the next level of ownership and control interests information. Complete this section for each business unit previously disclosed in point 2.a and each subsequent business unit. Details – Explain the details in their entirety, including the state and county where the conviction took place, the case number(s), the program involved, and most importantly what the person or company was convicted of. Contact Name – Enter the name of the person who can answer questions about the information provided in the form. The disclosing entity is required to fully disclose any interest or controlling interest in the disclosing entity and to disclose all entities and persons at all levels of ownership, from the ownership of the disclosing entity to the ownership of each subsequent owner company.

The disclosing company is also required to designate all employee managers at each level of ownership. Another disclosing entity is any other Medicaid entity and entity that does not participate in Medicaid, but is required to disclose certain ownership and control information due to participation in any of the programs set forth in Titles V, XVIII, XX, or XXI of the Social Security Act. If both questions are answered yes, provide the requested information. Note: A secured obligation to a business entity that is a financial institution regulated by a federal or state agency does not need to be disclosed. If additional entries are required for full disclosure, copy this page and add it as an attachment. Use a separate page for each business unit exposed at each level of the ownership structure. .

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