State Form 8200 - Application For License To Operate A Health Faclity - Indiana State Department Of Health Page 3

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C. Type of Change of Ownership

• •

Assignment of Interest

Lease

Merger

New Partnership

• •

Sale

Sublease

Termination of Lease

Other________________

D. Type of Entity

For Profit

NonProfit

Government

• •

Individual

Church Related

State

• •

* Partnership

Individual

County

• •

** Corporation

* Partnership

City

• •

*** Limited Liability Company

** Corporation

City/County

• •

Other (specify) _____________________________

*** Limited Liability Company

Hospital District

• •

_____________________________________________

Other (specify) _____________________

Federal

• •

_____________________________________________

_____________________________________

Other (specify) ________________

*If a Limited Partnership, submit a copy of the “Application For Registration” and “Certificate of Registration” signed by the Indiana Secretary of State.

**If a Corporation, submit a copy of the “Articles of Incorporation” and “Certificate of Incorporation” signed by the Indiana Secretary of State. If a foreign

Corporation, submit a copy of the “Certificate to do Business in the State of Indiana” signed by the Indiana Secretary of State.

***If a Limited Liability Company, submit a copy of the “Articles of Organization” and the “Certificate of Organization” signed by the Indiana Secretary of

State.

SECTION V - DISCLOSURE OF APPLICANT ENTITY

A. Officers/Directors/Members/Partners/Managers

1. List all individuals (persons) associated with the applicant entity and indicate the individual’s title (i.e. officer, director, member, partner,

etc). If the applicant is a partnership, list the name and title of each partner or the name and title of all individuals associated with each entity

that forms the partnership. If the applicant is a Limited Liability Company, list the name and title for all individuals associated with each

member entity that forms the Limited Liability Company.

(use additional sheet if necessary)

Name

Title

Business Address

Telephone Number

2. Are any individuals (persons) associated with the applicant entity (as listed in Sections IV.B and V.A.1) also associated with any other entity operating

• •

health facilities in Indiana or any other states?

Yes

If “yes,” list names and addresses of facilities owned by each individual.

(use additional sheet if necessary)

Facility Name

Address

City, County, State, Zip Code