DADS or HHSC Form

Texas Department of Aging
and Disability Services
Attention!
Form 5871
December 2015
Disclosure of Ownership and Control Statement
Carefully read all of the instructions to the form before completing this form. Errors and omissions will delay
processing. You may be able to use Form 5871-S, Disclosure of Ownership and Control Statement – Short Form, in
lieu of using this form. See instructions to Form 5871-S to determine if you meet the requirements.
Section 1. Disclosing Entity Information
Legal Name of Disclosing Entity (applicant/provider)
Doing Business As (d/b/a), if applicable
Name of Contact Person
Title or Relationship to Disclosing Entity
Area Code and Telephone No.
Area Code and Fax No.
Email Address
Business Entity Type
Sole Proprietor
For-profit Corporation
Publicly Traded
Nonprofit Corporation
Governmental (check one):
Federal
Taxpayer Identification No. (EIN or SSN)
State
General Partnership
Limited Liability Company
Limited Partnership
Trust, Living Trust or Estate
Limited Liability Partnership
Other (specify):
County
City
Hospital District/Authority
LIDDA
Provider Identifier No. (NPI or API)
Section 2. Disclosing Entity’s Ownership and Control Interest Information
See Exhibit A of the instructions for a list of required ownership and control interest disclosures by business entity type. Disclose business
entities with an ownership interest in 2.a. and individuals with an ownership or control interest and managing employees in 2.b.
2.a. Business Entity Ownership Interest
Legal Name of Business Entity
Business Entity Type
Physical Address (Street, City, State, ZIP Code)
Employer Identification No. (EIN)
Shares Publicly Traded? Percent of Ownership
Yes
Legal Name of Business Entity
Business Entity Type
Physical Address (Street, City, State, ZIP Code)
No
NA
Employer Identification No. (EIN)
Shares Publicly Traded? Percent of Ownership
Yes
Legal Name of Business Entity
Business Entity Type
Physical Address (Street, City, State, ZIP Code)
No
NA
Employer Identification No. (EIN)
Shares Publicly Traded? Percent of Ownership
Yes
No
NA
2.b. Individual Ownership or Control Interest; Managing Employees
First Name of Individual
Social Security No.
Last Name
Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosing Entity
Physical Address (Street, City, State, ZIP Code)
First Name of Individual
Social Security No.
MI
Percent of Ownership
Driver License No.
Last Name
Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosing Entity
Physical Address (Street, City, State, ZIP Code)
Jr., Sr., etc.
MI
State
Jr., Sr., etc.
Percent of Ownership
Driver License No.
State
Form 5871
Page 2 / 12-2015
Section 2. Disclosing Entity’s Ownership and Control Interest Information (continued)
2.b. Individual Ownership or Control Interest; Managing Employees (continued)
First Name of Individual
Social Security No.
Last Name
Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosing Entity
Physical Address (Street, City, State, ZIP Code)
First Name of Individual
Social Security No.
MI
Jr., Sr., etc.
Percent of Ownership
Last Name
MI
Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosing Entity
State
Jr., Sr., etc.
Percent of Ownership
Driver License No.
Last Name
MI
Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosing Entity
Physical Address (Street, City, State, ZIP Code)
State
Jr., Sr., etc.
Percent of Ownership
Driver License No.
Last Name
MI
Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosing Entity
Physical Address (Street, City, State, ZIP Code)
State
Driver License No.
Physical Address (Street, City, State, ZIP Code)
Social Security No.
Jr., Sr., etc.
Percent of Ownership
Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosing Entity
First Name of Individual
State
Driver License No.
Physical Address (Street, City, State, ZIP Code)
Social Security No.
MI
Last Name
First Name of Individual
Jr., Sr., etc.
Driver License No.
Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosing Entity
First Name of Individual
State
Percent of Ownership
Last Name
First Name of Individual
Social Security No.
MI
Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosing Entity
Physical Address (Street, City, State, ZIP Code)
Social Security No.
Percent of Ownership
Last Name
First Name of Individual
Jr., Sr., etc.
Driver License No.
Physical Address (Street, City, State, ZIP Code)
Social Security No.
MI
State
Jr., Sr., etc.
Percent of Ownership
Driver License No.
State
2.c. For for-profit corporations only
Has 100% ownership interest been disclosed in Section 2.a and 2.b? ................................................................................
Yes
No
If No, does each of the remaining shareholders (entities and individuals) own less than 5%? ...........................................
Yes
No
If No, disclose remaining shareholders that have a 5% or more ownership interest or attach an explanation why these
shareholders are not disclosed.
Copy this page to use as an attachment if more entries are required.
Form 5871
Page 3 / 12-2015
Section 3. Disclosing Entity’s Ownership and Control Interest Information: Next Level(s)
See Exhibit A of the instructions for a list of required ownership and control interest disclosures by business entity type. Disclose business
entities with an ownership interest in 3.a. and individuals with an ownership or control interest and managing employees in 3.b.
Legal Name of Business Entity Disclosed on This Page
Section 3.a. Business Entity Ownership Interest
Legal Name of Business Entity
Business Entity Type
Physical Address (Street, City, State, ZIP Code)
Employer Identification No.
(EIN)
Shares Publicly Traded? Percent of Ownership
Yes
Legal Name of Business Entity
Business Entity Type
Physical Address (Street, City, State, ZIP Code)
NA
Employer Identification No.
(EIN)
Shares Publicly Traded? Percent of Ownership
Yes
Legal Name of Business Entity
No
Business Entity Type
Physical Address (Street, City, State, ZIP Code)
No
NA
Employer Identification No.
(EIN)
Shares Publicly Traded? Percent of Ownership
Yes
No
NA
Section 3.b. Individual Ownership or Control Interest; Managing Employees
First Name of Individual
Social Security No.
Last Name
Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity
Physical Address (Street, City, State, ZIP Code)
First Name of Individual
Social Security No.
MI
Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity
Percent of Ownership
Last Name
MI
Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity
First Name of Individual
State
Jr., Sr., etc.
Percent of Ownership
Driver License No.
Last Name
MI
Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity
Physical Address (Street, City, State, ZIP Code)
State
Jr., Sr., etc.
Driver License No.
Physical Address (Street, City, State, ZIP Code)
Social Security No.
Percent of Ownership
Last Name
First Name of Individual
Jr., Sr., etc.
Driver License No.
Physical Address (Street, City, State, ZIP Code)
Social Security No.
MI
State
Jr., Sr., etc.
Percent of Ownership
Driver License No.
Copy this page to use as an attachment if more entries are required.
State
Form 5871
Page 4 / 12-2015
Section 3. Disclosing Entity’s Ownership and Control Interest Information: Next Level(s) (continued)
Section 3.b. Individual Ownership or Control Interest; Managing Employees (continued)
First Name of Individual
Social Security No.
Last Name
Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity
Physical Address (Street, City, State, ZIP Code)
First Name of Individual
Social Security No.
Jr., Sr., etc.
Percent of Ownership
MI
Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity
State
Jr., Sr., etc.
Percent of Ownership
Driver License No.
Last Name
MI
Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity
Physical Address (Street, City, State, ZIP Code)
State
Jr., Sr., etc.
Percent of Ownership
Driver License No.
Last Name
MI
Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity
Physical Address (Street, City, State, ZIP Code)
State
Driver License No.
Physical Address (Street, City, State, ZIP Code)
Social Security No.
MI
Last Name
First Name of Individual
Jr., Sr., etc.
Driver License No.
Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity
First Name of Individual
State
Percent of Ownership
Last Name
First Name of Individual
Social Security No.
MI
Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity
Physical Address (Street, City, State, ZIP Code)
Social Security No.
Percent of Ownership
Last Name
First Name of Individual
Jr., Sr., etc.
Driver License No.
Physical Address (Street, City, State, ZIP Code)
Social Security No.
MI
State
Jr., Sr., etc.
Percent of Ownership
Driver License No.
State
3.c. For for-profit corporations only
Has 100% ownership interest been disclosed in Section 3.a and 3.b? ................................................................................
Yes
No
If No, does each of the remaining shareholders (entities and individuals) own less than 5%? ............................................
Yes
No
If No, disclose remaining shareholders that have a 5% or more ownership interest or attach an explanation why these
shareholders are not disclosed.
Copy this page to use as an attachment if more entries are required.
Form 5871
Page 5 / 12-2015
Note: If the disclosing entity does not contract or propose to contract with a management company to perform any services related
to its participation in DADS programs, check the box NA, leave sections 4 through 6 blank and go to Section 7.
NA
Section 4. Management Company Information
Legal Name of Business Entity
Business Entity Type
Employer Identification No. (EIN)
Physical Address (Street, City, State, ZIP Code)
Mailing Address (P.O. Box or Street, City, State, ZIP Code), if different
Name of Contact Person
Title or Relationship to Management Company
Area Code and Telephone
No.
Area Code and Fax No.
Email Address
Section 5. Management Company’s Ownership and Control Interest Information
See Exhibit A of the instructions for a list of required ownership and control interest disclosures by business entity type. Disclose business
entities with an ownership interest in 5.a. and individuals with an ownership or control interest and managing employees in 5.b.
Section 5.a. Business Entity Ownership Interest
Legal Name of Business Entity
Business Entity Type
Physical Address (Street, City, State, ZIP Code)
Employer Identification No. (EIN)
Shares Publicly Traded? Percent of Ownership
Yes
Legal Name of Business Entity
Business Entity Type
Physical Address (Street, City, State, ZIP Code)
NA
Employer Identification No. (EIN)
Shares Publicly Traded? Percent of Ownership
Yes
Legal Name of Business Entity
No
Business Entity Type
Physical Address (Street, City, State, ZIP Code)
No
NA
Employer Identification No. (EIN)
Shares Publicly Traded? Percent of Ownership
Yes
No
NA
Section 5.b. Individual Ownership or Control Interest; Managing Employees
First Name of Individual
Social Security No.
Last Name
Date of Birth (mm/dd/yyyy) Title or Position Held with Management Company
Physical Address (Street, City, State, ZIP Code)
First Name of Individual
Social Security No.
Percent of Ownership
Last Name
MI
Date of Birth (mm/dd/yyyy) Title or Position Held with Management Company
First Name of Individual
State
Jr., Sr., etc.
Percent of Ownership
Driver License No.
Last Name
MI
Date of Birth (mm/dd/yyyy) Title or Position Held with Management Company
Physical Address (Street, City, State, ZIP Code)
Jr., Sr., etc.
Driver License No.
Physical Address (Street, City, State, ZIP Code)
Social Security No.
MI
State
Jr., Sr., etc.
Percent of Ownership
Driver License No.
Copy this page to use as an attachment if more entries are required.
State
Form 5871
Page 6 / 12-2015
Section 5. Management Company’s Ownership and Control Interest Information (continued)
Section 5.b. Individual Ownership or Control Interest; Managing Employees (continued)
First Name of Individual
Social Security No.
Last Name
Date of Birth (mm/dd/yyyy) Title or Position Held with Management Company
Physical Address (Street, City, State, ZIP Code)
First Name of Individual
Social Security No.
MI
Jr., Sr., etc.
Percent of Ownership
Last Name
MI
Date of Birth (mm/dd/yyyy) Title or Position Held with Management Company
State
Jr., Sr., etc.
Percent of Ownership
Driver License No.
Last Name
MI
Date of Birth (mm/dd/yyyy) Title or Position Held with Management Company
Physical Address (Street, City, State, ZIP Code)
State
Jr., Sr., etc.
Percent of Ownership
Driver License No.
Last Name
MI
Date of Birth (mm/dd/yyyy) Title or Position Held with Management Company
Physical Address (Street, City, State, ZIP Code)
State
Driver License No.
Physical Address (Street, City, State, ZIP Code)
Social Security No.
Jr., Sr., etc.
Percent of Ownership
Date of Birth (mm/dd/yyyy) Title or Position Held with Management Company
First Name of Individual
State
Driver License No.
Physical Address (Street, City, State, ZIP Code)
Social Security No.
MI
Last Name
First Name of Individual
Jr., Sr., etc.
Driver License No.
Date of Birth (mm/dd/yyyy) Title or Position Held with Management Company
First Name of Individual
State
Percent of Ownership
Last Name
First Name of Individual
Social Security No.
MI
Date of Birth (mm/dd/yyyy) Title or Position Held with Management Company
Physical Address (Street, City, State, ZIP Code)
Social Security No.
Percent of Ownership
Last Name
First Name of Individual
Jr., Sr., etc.
Driver License No.
Physical Address (Street, City, State, ZIP Code)
Social Security No.
MI
State
Jr., Sr., etc.
Percent of Ownership
Driver License No.
State
5.c. For for-profit corporations only
Has 100% ownership interest been disclosed in Section 5.a and 5.b? ................................................................................
Yes
No
If No, does each of the remaining shareholders (entities and individuals) own less than 5%? ............................................
Yes
No
If No, disclose remaining shareholders that have a 5% or more ownership interest or attach an explanation why these
shareholders are not disclosed.
Copy this page to use as an attachment if more entries are required.
Form 5871
Page 7 / 12-2015
Section 6. Management Company’s Ownership and Control Interest Information: Next Level(s)
See Exhibit A of the instructions for a list of required ownership and control interest disclosures by business entity type. Disclose business
entities with an ownership interest in 6.a. and individuals with an ownership or control interest and managing employees in 6.b.
Legal Name of Business Entity Disclosed on This Page
Section 6.a. Business Entity Ownership Interest
Legal Name of Business Entity
Business Entity Type
Physical Address (Street, City, State, ZIP Code)
Employer Identification No. (EIN)
Shares Publicly Traded? Percent of Ownership
Yes
Legal Name of Business Entity
Business Entity Type
Physical Address (Street, City, State, ZIP Code)
NA
Employer Identification No. (EIN)
Shares Publicly Traded? Percent of Ownership
Yes
Legal Name of Business Entity
No
Business Entity Type
Physical Address (Street, City, State, ZIP Code)
No
NA
Employer Identification No. (EIN)
Shares Publicly Traded? Percent of Ownership
Yes
No
NA
Section 6.b. Individual Ownership or Control Interest; Managing Employees
First Name of Individual
Social Security No.
Last Name
Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity
Physical Address (Street, City, State, ZIP Code)
First Name of Individual
Social Security No.
MI
Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity
Jr., Sr., etc.
Driver License No.
MI
Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity
State
Jr., Sr., etc.
Percent of Ownership
Driver License No.
Last Name
MI
Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity
Physical Address (Street, City, State, ZIP Code)
State
Percent of Ownership
Last Name
First Name of Individual
Jr., Sr., etc.
Driver License No.
Physical Address (Street, City, State, ZIP Code)
State
Percent of Ownership
Last Name
First Name of Individual
Social Security No.
MI
Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity
Physical Address (Street, City, State, ZIP Code)
Social Security No.
Percent of Ownership
Last Name
First Name of Individual
Jr., Sr., etc.
Driver License No.
Physical Address (Street, City, State, ZIP Code)
Social Security No.
MI
State
Jr., Sr., etc.
Percent of Ownership
Driver License No.
Copy this page to use as an attachment if more entries are required.
State
Form 5871
Page 8 / 12-2015
Section 6. Management Company’s Ownership and Control Interest Information: Next Level(s) (continued)
Section 6.b. Individual Ownership or Control Interest; Managing Employees (continued)
First Name of Individual
Social Security No.
Last Name
Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity
Physical Address (Street, City, State, ZIP Code)
First Name of Individual
Social Security No.
MI
Jr., Sr., etc.
Percent of Ownership
Last Name
MI
Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity
State
Jr., Sr., etc.
Percent of Ownership
Driver License No.
Last Name
MI
Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity
Physical Address (Street, City, State, ZIP Code)
State
Jr., Sr., etc.
Percent of Ownership
Driver License No.
Last Name
MI
Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity
Physical Address (Street, City, State, ZIP Code)
State
Driver License No.
Physical Address (Street, City, State, ZIP Code)
Social Security No.
Jr., Sr., etc.
Percent of Ownership
Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity
First Name of Individual
State
Driver License No.
Physical Address (Street, City, State, ZIP Code)
Social Security No.
MI
Last Name
First Name of Individual
Jr., Sr., etc.
Driver License No.
Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity
First Name of Individual
State
Percent of Ownership
Last Name
First Name of Individual
Social Security No.
MI
Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity
Physical Address (Street, City, State, ZIP Code)
Social Security No.
Percent of Ownership
Last Name
First Name of Individual
Jr., Sr., etc.
Driver License No.
Physical Address (Street, City, State, ZIP Code)
Social Security No.
MI
State
Jr., Sr., etc.
Percent of Ownership
Driver License No.
State
6.c. For for-profit corporations only
Has 100% ownership interest been disclosed in Section 6.a and 6.b? ................................................................................
Yes
No
If No, does each of the remaining shareholders (entities and individuals) own less than 5%? ............................................
Yes
No
If No, disclose remaining shareholders that have a 5% or more ownership interest or attach an explanation why these
shareholders are not disclosed.
Copy this page to use as an attachment if more entries are required.
Form 5871
Page 9 / 12-2015
Section 7. Other Ownership and Control Interest Information
7.a. Does any business entity or individual have a 5% or greater ownership interest in any mortgage, deed of trust,
note or other obligation secured by the disclosing entity? .............................................................................................
Yes
No
If yes, does the business entity’s or individual’s ownership interest equal at least 5% of the value of the disclosing
entity’s assets? .............................................................................................................................................................
Yes
No
If yes, compete the following for the business entity or individual. Note: A secured obligation with a business entity
that is a financial institution regulated by a federal or state governmental agency does not have to be disclosed.
Legal Name of Business Entity
Employer Identification No. (EIN)
Physical Address (Street, City, State, ZIP Code)
Legal Name of Business Entity
Employer Identification No. (EIN)
Physical Address (Street, City, State, ZIP Code)
Name of Individual
Social Security No.
Physical Address (Street, City, State, ZIP Code)
Date of Birth (mm/dd/yyyy)
Driver License No.
Name of Individual
Social Security No.
Physical Address (Street, City, State, ZIP Code)
State
Date of Birth (mm/dd/yyyy)
Driver License No.
State
7.b. Does the disclosing entity have a 5% or greater ownership interest in any subcontractor? ..........................................
Yes
No
If yes, will the subcontractor perform any services related to the disclosing entity’s participation in
DADS programs? ..........................................................................................................................................................
Yes
No
If yes, compete the following for the subcontractor.
Legal Name of Business Entity (Subcontractor)
Business Entity Type
Employer Identification No. (EIN)
Physical Address (Street, City, State, ZIP Code)
Disclosing Entity’s Percentage of Ownership in Subcontractor
Provide the name, federal taxpayer ID number and address of all other individuals or business entities that have a 5% or more ownership
interest or control interest in the subcontractor listed above.
Name of Individual or Business Entity
SSN or EIN
Physical Address (Street, City, State, ZIP Code)
Name of Individual or Business Entity
SSN or EIN
Physical Address (Street, City, State, ZIP Code)
Name of Individual or Business Entity
SSN or EIN
Physical Address (Street, City, State, ZIP Code)
Name of Individual or Business Entity
SSN or EIN
Physical Address (Street, City, State, ZIP Code)
Name of Individual or Business Entity
SSN or EIN
Physical Address (Street, City, State, ZIP Code)
Copy this page to use as an attachment if more entries are required.
Form 5871
Page 10 / 12-2015
Section 7. Other Ownership and Control Interest Information
7.c. Are any individuals identified in Section 2, 3, 4, 5, 6 or 7.a. or 7.b. related to each other as a spouse, natural or
adoptive parent, natural or adoptive child, or natural or adoptive sibling? ....................................................................
Yes
No
If yes, compete the following for the related individuals.
Name of First Individual
Identified in Section
Name of Second Individual
Identified in Section
2
2
3
3
4
5
6
7
4
5
6
7
4
5
6
7
4
5
6
7
4
5
6
7
4
5
6
7
4
5
6
7
4
5
6
7
Relationship of First Individual to Second Individual
Spouse
Parent
Child
Sibling
Name of First Individual
Identified in Section
Name of Second Individual
Identified in Section
2
2
3
3
Relationship of First Individual to Second Individual
Spouse
Parent
Child
Sibling
Name of First Individual
Identified in Section
Name of Second Individual
Identified in Section
2
2
3
3
Relationship of First Individual to Second Individual
Spouse
Parent
Child
Sibling
Name of First Individual
Identified in Section
Name of Second Individual
Identified in Section
2
2
3
3
Relationship of First Individual to Second Individual
Spouse
Parent
Child
Sibling
7.d. Does any disclosing entity owner identified in Section 2 or 3 have an ownership or control interest in any other
disclosing entity? ...........................................................................................................................................................
Yes
No
If yes, compete the following for the individual or business entity.
Name of Individual/Business Entity
Identified in Section
2
3
4
5
6
7
4
5
6
7
4
5
6
7
Name of Other Disclosing Entity
Name of Individual/Business Entity
Identified in Section
2
3
Name of Other Disclosing Entity
Name of Individual/Business Entity
Identified in Section
2
Name of Other Disclosing Entity
Copy this page to use as an attachment if more entries are required.
3
Form 5871
Page 11 / 12-2015
Section 8. General Disclosure Questions
8.a. Has any individual or business entity identified in Section 2, 3, 4, 5, 6 or 7.a. or 7.b. ever been convicted of a
criminal offense related to any program established by Titles XVIII, XIX, XX or XXI? ..................................................
Yes
No
If yes, identify the individual or business entity below and fully explain the details, including the state and county
the conviction occurred, the cause number(s), the program affected, and specifically what the individual or
business entity was convicted of. (Attach additional sheets, if necessary.)
Name of Individual/Business Entity
Identified in Section
2
3
4
5
6
7
4
5
6
7
4
5
6
7
Details:
Name of Individual/Business Entity
Identified in Section
2
3
Details:
Name of Individual/Business Entity
Identified in Section
2
3
Details:
8.b. Has any individual or business entity identified in Section 2, 3, 4, 5, 6 or 7.a. or 7.b. ever been sanctioned in any
state or federal program? ..............................................................................................................................................
Yes
No
If yes, identify the individual or business entity below and fully explain the details, including the date, the state the
incident occurred, the agency taking the action and the program affected. (Attach additional sheets, if necessary.)
Name of Individual/Business Entity
Identified in Section
2
3
4
5
6
7
4
5
6
7
4
5
6
7
Details:
Name of Individual/Business Entity
Identified in Section
2
3
Details:
Name of Individual/Business Entity
Identified in Section
2
Details:
Copy this page to use as an attachment if more entries are required.
3
Form 5871
Page 12 / 12-2015
Section 8. General Disclosure Questions (continued)
8.c. Is any individual or business entity identified in Section 2, 3, 4, 5, 6 or 7.a. or 7.b. currently or ever been subject to
the terms of a settlement agreement, corporate compliance agreement or corporate integrity agreement in relation
to any state or federally funded program? ...................................................................................................................
Yes
No
If yes, identify the individual or business entity below and fully explain the details, including date, term, the state
where the incident occurred, program affected and the name of the board or agency. (Attach additional sheets, if
necessary.)
Name of Individual/Business Entity
Identified in Section
2
3
4
5
6
7
4
5
6
7
4
5
6
7
Details:
Name of Individual/Business Entity
Identified in Section
2
3
Details:
Name of Individual/Business Entity
Identified in Section
2
3
Details:
8.d. Does any individual or business entity identified in Section 2, 3, 4, 5, 6 or 7.a. or 7.b. have an outstanding debt in
relation to any state or federally funded program?. ......................................................................................................
If yes, identify the individual or business entity below and fully explain the details, including amount, payment
status (current or delinquent), the state where the incident occurred, and the name of the board or agency. (Attach
additional sheets, if necessary.)
Name of Individual/Business Entity
Yes
No
Identified in Section
2
3
4
5
6
7
4
5
6
7
4
5
6
7
Details:
Name of Individual/Business Entity
Identified in Section
2
3
Details:
Name of Individual/Business Entity
Identified in Section
2
Details:
Copy this page to use as an attachment if more entries are required.
3
Form 5871
Page 13 / 12-2015
Section 8. General Disclosure Questions (continued)
8.e. Is any individual or business entity identified in Section 2, 3, 4, 5, 6 or 7.a or 7.b. currently charged with or ever
been convicted a criminal offense listed in Texas Administrative Code, Title 40, Part 1, Chapter 49, §49.206 ? ........
Yes
No
If yes, identify the individual or business entity below and fully explain the details, including date, the state and
county the conviction occurred, the cause number(s), and specifically what the individual or business entity was
convicted of. Do not include any conviction disclosed in question 8.a. (Attach additional sheets, if necessary.)
Name of Individual/Business Entity
Identified in Section
2
3
4
5
6
7
4
5
6
7
4
5
6
7
Details:
Name of Individual/Business Entity
Identified in Section
2
3
Details:
Name of Individual/Business Entity
Identified in Section
2
3
Details:
8.f.
Does any individual identified in Section 2, 3, 4, 5, 6 or 7.a. or 7.b. have a professional license or certification that
is currently revoked, suspended or otherwise restricted? ............................................................................................
Yes
No
Has any individual’s license or certification ever been revoked, suspended or otherwise restricted? ..........................
Yes
No
Is any individual currently, or ever been, subject to a licensing or certification board order? .......................................
Yes
No
Has any individual voluntarily surrendered a license or certification in lieu of disciplinary action? ...............................
Yes
No
If yes is answered to any of these questions, identify the individual below and fully explain the details, including
date, state in which the incident occurred, name of the board or agency, and any adverse action taken against the
individual’s license.
Name of Individual
Identified in Section
2
3
4
5
6
7
4
5
6
7
Details:
Name of Individual
Identified in Section
2
Details:
Copy this page to use as an attachment if more entries are required.
3
Form 5871
Page 14 / 12-2015
Section 8. General Disclosure Questions (continued)
8.g. Is any individual identified in Section 2, 3, 4, 5, 6 or 7.a. or 7.b. currently behind 30 days or more on court ordered
child support? ...............................................................................................................................................................
Yes
No
If yes, identify the individual below and provide details on how these past-due obligations will be met. (Attach
additional sheets, if necessary.)
Name of Individual
Identified in Section
2
3
4
5
6
7
4
5
6
7
4
5
6
7
Details:
Name of Individual
Identified in Section
2
3
Details:
Name of Individual
Identified in Section
2
3
Details:
8.h. Is any individual identified in Section 2, 3, 4, 5, 6 or 7.a or 7.b. not a citizen of the United States? .............................
Yes
No
If yes, identify the individual below and provide the name of the country the individual is a citizen of.
Name of Individual
Identified in Section
2
3
4
5
6
7
4
5
6
7
4
5
6
7
Name of Country:
Name of Individual
Identified in Section
2
3
Name of Country:
Name of Individual
Identified in Section
2
3
Name of Country:
8.i.
Does any individual identified in question 8.h. have a legal right to work in the United States? ..................................
If yes, attach a copy the individual’s green card, visa or other documentation demonstrating the individual’s right to
work and reside in the United States.
Copy this page to use as an attachment if more entries are required.
Yes
No
Form 5871
Page 15 / 12-2015
Section 9. Disclosing Entity’s Certification
I certify the information set forth in this form and all attachments, if any, is true and complete. If found to be otherwise, I understand it is
sufficient cause for DADS to deny the disclosing entity’s application to enroll in Texas Medicaid, the disclosing entity’s community services
contract application or, if applicable, terminate the disclosing entity’s existing contract. I also understand that as a condition of participation in
DADS programs, the information provided in this form must be kept current, and I agree to submit updated information in accordance with
Texas Administrative Code Title 40, Part 1, Chapter 49 (relating to Contracting for Community Services).
Signature–Owner or Authorized Representative
Typed or Printed Name of Owner or Authorized Representative
Date
Title
With a few exceptions, you have the right to request and be informed about the information the Department of Aging and Disability
Services (DADS) obtains about you. You are entitled to receive and review the information upon request. You also have the right to ask
DADS to correct information that is determined to be incorrect (Government Code, §§552.021, 552.023, 559.004). To find out about your
information and your right to request correction, please refer to the DADS contact information in your application, procurement or renewal
packet.