Ownership and Control Interest Disclosure Statement

Do you have a business or businesses to disclose?

YesNo
Warning! You must disclose either a person in the previous section or a business in this section. You can do either or both, but you may not leave both sections blank.
If you need to disclose a person, go back to the previous section, otherwise check Yes to disclose a business in this section.

Business #1
You are:*

a Subcontractoran OwnerOther (please specify)
If person is listed because of ownership/control of a subcontractor, name the subcontractor.*
List percent of ownership interest if 5% or more.*
Full Legal Name*
FEIN*
Business Address*

Street Address

Street Address Line 2

CityState

Zip Code
County of Business Address*
Ownership or Control Interest*

Begin DateEnd Date
Begin Date*

MonthDayYear
MM/DD/YYYY
End Date

MonthDayYear
MM/DD/YYYY
Check this box if your business has no business ownership or control interest.

No business ownership or control interest.
Add another business?

YesNo

Business #2
You are:*

a Subcontractoran OwnerOther (please specify)
If person is listed because of ownership/control of a subcontractor, name the subcontractor.*
List percent of ownership interest if 5% or more.*
Full Legal Name*
FEIN*
Business Address*

Street Address

Street Address Line 2

CityState

Zip Code
County of Business Address*
Ownership or Control Interest*

Begin DateEnd Date
Begin Date*

MonthDayYear
MM/DD/YYYY
End Date

MonthDayYear
MM/DD/YYYY
Check this box if your business has no business ownership or control interest.

No business ownership or control interest.
Add another business?

YesNo

Business #3
You are a(n):*

SubcontractorOwnerOther (please specify)
If person is listed because of ownership/control of a subcontractor, name the subcontractor.*
List percent of ownership interest if 5% or more.*
Full Legal Name*
FEIN*
Business Address*

Street Address

Street Address Line 2

CityState

Zip Code
County of Business Address*
Ownership or Control Interest*

Begin DateEnd Date
Begin Date*

MonthDayYear
MM/DD/YYYY
End Date

MonthDayYear
MM/DD/YYYY
Check this box if your business has no business ownership or control interest.

No business ownership or control interest.
Do you have more than 3 businesses to report?

YesNo
To report more than 3 businesses email compliance@mnscha.org.

Complete the following information for each person, business or organization previously listed that has an ownership or control interest in any other Medicaid disclosing entity or for any entity that is otherwise required to disclose ownership and control information because of participation in Title V, XVIII or XX programs.

If there is no other ownership or control interest for a person, business, or organization previous listed, this section is not required. Please proceed to the next step.
Entity #1
Full Legal Name (Person: Last, First, MI; Business: Taxpayer name as listed with IRS)
Percent of Ownership Interest
Full Legal Name of Other Provider
Address of Other Provider

Street Address

Street Address Line 2

CityState

Zip Code
County of Other Provider Address
Add Another?

YesNo

Entity #2
Full Legal Name (Person: Last, First, MI; Business: Taxpayer name as listed with IRS)
Percent of Ownership Interest
Full Legal Name of Other Provider
Address of Other Provider

Street Address

Street Address Line 2

CityState

Zip Code
County of Other Provider Address
Do you have more than two entities to report?

YesNo
To report more than 2 entities email compliance@mnscha.org.

PCA Providers ONLY:

Complete the following information for all residential properties you own, lease, or manage that could be or are used for providing home care services.
Full Legal Name of Residence/Provider (Taxpayer name of FEIN or on W-9 from IRS)*
Address of Property*

Street Address

Street Address Line 2

CityState

Zip Code
Do You Own, Lease or Manage the Property?*

OwnLeaseManage
County where Property is Located*

I am signing this form electronically. My name as typed in the signature field is my legally binding signature. I understand that my electronic signature has the same legal effect and can be enforced in the same way as a handwritten signature. (MN Statutes 325L.02(h), 325L.05 and 325L.08)

By signing below, I, an authorized officer (CEO, president) with authority to bind the entity, certify that:
• The information on this form is true and correct.
• I will notify South Country of any changes to this information.
Name*

First NameMiddle InitialLast Name
Title*
Email*
Phone Number*
Please enter a valid phone number.
Date*

MonthDayYear
Date
Should be Empty: