Application Form & Full Disclosure Of Ownership Statement For An Amended License By A Non-Profit Corporation Or Governmental Unit Page 2

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Division of Public Health–Licensure Unit–Children's Services Licensing

Application & Full Disclosure of Ownership Statement for an Amended License

by a Non-Profit Corporation or Governmental Unit

READ CAREFULLY, USE BLACK INK, PRINT LEGIBLY AND FOLLOW ENCLOSED INSTRUCTIONS

SECTION b - OWNERSHIP INFORMATION:

use an additional form if more space is needed to make full

disclosure of ownership. Non-Profit Corporation status will be verified with the Secretary of State.

buSINESS OWNERSHIP: (CHECK ONE)



Non-Profit Corporation

Governmental unit

IF A GOVERNMENT uNIT: (CHECK ONE)



State

District (i.e. School)

County

City

Tribal

13. Ownership of Program: _____________________________________________________________________________________________________________

Legal Name(s) of: Non-Profit Corporation or Governmental Unit

14. Federal Identification Number (FID) of Corporation or Governmental Unit: ____________________________________________________

15. Secretary of State Account Number: ___________________________________________________________________________________

16. Mailing address if different than #11 in Section A above: __________________________________________________________________

17. Phone Number/Cell Phone Number with Area Code if different than #3 in Section A above: _______________________________________

18. Email (optional) if different than #5 in Section A above: ________________________________________________________________________________

I/we have read the Rules and Regulations issued by the Nebraska Department of Health and Human Services, Division of Public Health,

Licensure Unit and will comply with them should a license be issued. I/we have fully disclosed all owners of the program, regardless of

whether an owner participates in the operation of the program.

When the applicant is a non-profit corporation, the application for a Provisional license and an Operating license must be signed by two

officers that have authority to bind the corporation to the terms of the application or one signature will be accepted if the articles of incorporation

are submitted with the application.

When the applicant is a governmental unit, the application for a Provisional license and an Operating license must be signed by the head of

the governmental unit having jurisdiction over the facility to be licensed.

I/we certify that to the best of my/our knowledge, all information and statements on this Application and Full Disclosure of Ownership document

are true and correct.

_______________________________________________

________________________________________

___________________

Print Name and Title

Signature

Date

_______________________________________________