Disclosure of Ownership Interest. 8.17.1 The Developer, at the filing of its initial application, completed a Disclosure of Ownership Interest form with the City. The Developer hereby states, certifies and confirms to the City that the information on that form is still true and correct as of the Effective Date, if not then the form shall be revised if necessary. The Disclosure of Ownership Interest form shall be attached as Exhibit “C” to this Agreement and is incorporated herein by reference and made a part hereof.
Disclosure of Ownership Interest. Pursuant to Chapter 2-000-000, 2-000-000, 2-000-000 and 2-000-000 of the Municipal Code of the City of Chicago, all grantees/ proposers shall provide the following information with their proposal. Notwithstanding, the Corporation Counsel may require an additional information which is reasonably intended to achieve full disclosure of ownership interests from grantee or proposer. Every question must be answered. If the question is not applicable, answer with “NA.” If the answer is none, please answer “None.” Note: The person preparing Section I, II, III, IV or V of this statement must sign the bottom of Page 4 before a Notary Public. Grantee/ Proposer Name: Unicom Thermal Technologies, Inc. Grantee/ Proposer Address: 30 Xxxx Xxxxxx, Xxxxx 000 Xxxxxxx, Xxxxxxxx 00000 Grantee/ Proposer is a : (x)Corporation; ( )Sole Proprietor; ( )Partnership; (Check One) ( )Not-for Profit Corporation ( )Joint Venturer*; ( )Other; *Each Joint Venture Partner must submit a completed Disclosure of Ownership Interest.
Disclosure of Ownership Interest. $2,500 per provider disclosure/attestation for each disclosure/attestation that is not received or is received and signed by a provider that does not request or contain complete and satisfactory disclosure of the requirements outlined in 42 C.F.R. part 455, subpart B.
Disclosure of Ownership Interest. The corporation is owned partially or completely by one or more other corporations: YES þ NO o
Disclosure of Ownership Interest a. Contractor shall provide, via Administrative Notice to OHA’s Contract Administrator, disclosures in accordance with 42 CFR §455.100 through 42 CFR §455.106 and, in particular 42 CFR §455.104(b), regarding each person or corporation with an ownership or Control interest (which equals or exceeds 5 percent) in Contractor , or any Subcontractor in which Contractor has an ownership interest that equals or exceeds five percent (5%), consistent with 42 CFR §455.104 to§ 455.106. Disclosures will be reviewed by OHA in accordance with 42 CFR §438.602(c) and
(1) Whether any of the persons named in this S. 18, Ex. B-Part 8 are related to one another as a spouse, parent, child or sibling. In accordance with 42 CFR §455.104(b) disclosures that shall be provided to OHA include the following:
(a) Name and address (the address for corporate entities must include as applicable primary business address, every business location, and P.O. Box address.)
(b) Date of birth and Social Security Number (in the case of an individual).
(c) Other tax identification number (in the case of a corporation)
(d) The name of any other Medicaid Provider or fiscal agent in which the person or corporation has an ownership or Control interest.
(e) The name, address, date of birth, and Social Security Number of any managing employee of the Contractor
(2) Name any other disclosing entity in which a person named in this S. 18, Ex. B-Part 8 also has an ownership or Controlling interest.
(3) Any person with an ownership or Control interest in a Subcontractor with whom the Contractor has had business transactions totaling more than $25,000 during a twelve (12) month period ending on the date or request; and any significant business transactions between Contractor and a wholly-owned supplier or between Contractor and a Subcontractor during a five (5) year period ending on the date of request.
(4) Any person who has an ownership or Controlling interest in the Contractor, or is an agent or managing employee of the Contractor, and has been convicted of a criminal offense related to that person’s involvement in any program under Medicare, Medicaid or other federal services program since inception of those programs.
b. Contractor shall provide OHA’s Contract Administrator with Administrative Notice of any Person who has an ownership or Controlling interest in the Contractor, or is an agent or managing employee of the Contractor of the events identified below in the time identified below as follows: at
(1)...
Disclosure of Ownership Interest.
a. Contractor shall provide disclosures in accordance with 42 CFR §455.100 through 42 CFR
(1) Whether any of the persons named in this Section 13 are related to one another as a spouse, parent, child or sibling. In accordance with 42 CFR §455.104(b) disclosures that shall be provided to OHA include the following:
(a) Name and address (the address for corporate entities must include as applicable primary business address, every business location, and P.O. Box address.)
(b) Date of birth and Social Security Number (in the case of an individual).
(c) Other tax identification number (in the case of a corporation)
(d) The name of any other Medicaid provider or fiscal agent in which the person or corporation has an ownership or control interest.
(e) The name, address, date of birth, and Social Security Number of any managing employee of the Contractor
(2) Name any other disclosing entity in which a person named in this Section 14 also has an ownership or controlling interest.
(3) Any person with an ownership or control interest in a Subcontractor with whom the Contractor has had business transactions totaling more than $25,000 during a 12 month period ending on the date or request; and any significant business transactions between Contractor and a wholly-owned supplier or between Contractor and a Subcontractor during a 5 year period ending on the date of request.
(4) Any person who has an ownership or controlling interest in the Contractor, or is an agent or managing employee of the Contractor, and has been convicted of a criminal offense related to that person’s involvement in any program under Medicare, Medicaid or other federal services program since inception of those programs.
b. Any person who has an ownership or controlling interest in the Contractor, or is an agent or managing employee of the Contractor shall submit to the OHA Contract Administration Unit the appropriate disclosures at the following times:
(1) Within at least 90 days prior to any changes in ownership or controlling interest of 5 percent or more;
(2) Upon request of OHA during re-evaluation of Enrollment processes under 42 CFR
(3) Within 35 days after any change in ownership, with equity shares transferred being less than 50%;
(4) When Contractor executes a contract with OHA; and
(5) When Contractor amends the contract with OHA through renewal or extension.
Disclosure of Ownership Interest a. Contractor shall provide OHA with full and complete information of each person or corporation with an ownership or control interest (which equals or exceeds 5 percent) in the Coordinated Care Organization, or any Subcontractor in which Contractor has an ownership interest that equals or exceeds 5 percent, consistent with 42 CFR 455.100 through 42 CFR 455.106, and include the following:
(1) Whether any of the persons named in Section 2 are related to one another as a spouse, parent, child or sibling.
(2) Name any other disclosing entity in which a person named in section 2 also has an ownership or controlling interest.
(3) Any person with an ownership or control interest in a Subcontractor with whom the provider has had business transactions totaling more than $25,000 during a 12 month period ending on the date or request; and any significant business transactions between provider and wholly-owned supplier or between provider and Subcontractor during a 5 year period ending on the date of request.
(4) Any person who has an ownership or controlling interest in the provider, or is an agent or managing employee of the provider, and has been convicted of a criminal offense related to that person’s involvement in any program under Medicare, Medicaid or other federal services program since inception of those programs.
Disclosure of Ownership Interest. In accordance with 42 C.F.R. § 438.608(c)(2), the Contractor shall provide to the Department written disclosures of Ownership and Control Interests as required under 42 C.F.R. § 455.104, including:
a. The name, address, date of birth, and Social Security Number or Tax Identification Number as applicable for any individual or corporation with a direct or indirect or combined Ownership or Control Interest in the Contractor, of five percent (5%) or more of the Contractor’s equity, owns five percent (5%) or more of any mortgage, deed of trust, note, or other obligation secured by the Contractor if that interest equals at least five percent (5%) of the value of the Contractor’s assets;
b. The name, address, date of birth, and Social Security Number of the Executive Director and the CEO of the Contractor;
c. Whether the person with an Ownership or Control Interest in the Contractor is related to another person with Ownership or Control Interest in the Contractor or a Subcontractor as a spouse, parent, child, or sibling;
d. The Name, Address, Date of Birth, and Social Security Number of the managing employees of the Contractor
i. Upon effective date of the Contract;
ii. Upon renewal or extension of the Contract; and
iii. Within thirty-five (35) days after any change in the Contractor’s ownership.
Disclosure of Ownership Interest in whose behalf title is held, including the name, address and percentage of interest of each beneficiary.
