C. Type of Change of Ownership
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• •
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Assignment of Interest
Lease
Merger
New Partnership
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• •
Sale
Sublease
Termination of Lease
Other________________
D. Type of Entity
For Profit
NonProfit
Government
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• •
• •
Individual
Church Related
State
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• •
• •
* Partnership
Individual
County
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** Corporation
* Partnership
City
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*** Limited Liability Company
** Corporation
City/County
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Other (specify) _____________________________
*** Limited Liability Company
Hospital District
• •
• •
_____________________________________________
Other (specify) _____________________
Federal
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_____________________________________________
_____________________________________
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
No
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
3