The owner or an authorized representative of the disclosing body confirms that the information provided on the form and all appendices, if any, is true and complete. If the legal entity is not a sole proprietorship, the authorized representative must be named on an up-to-date Form 2031, Governing Authority Resolution – Business Organization, or Form 2031-G, Governing Authority Resolution – Government Entity Filed with HHSC. Disclosure of the company`s percentage of the subcontractor`s ownership – Enter the percentage of the disclosing company`s stake in the subcontractor`s business unit. Contact Name – Enter the name of the person who can answer questions about the information provided in the form. Name of another disclosing entity – Enter the name of the other disclosing entity in which the above-mentioned physical or business entity has a right of ownership or control. Another disclosing company is any other Medicaid company and any company that does not participate in Medicaid, but is required to disclose certain ownership and control information due to participation in any of the programs set forth in Titles V, XVIII, XX, or XXI of the Social Security Act. enter the relevant d/b/a to this agreement. Note: A d/b/a is an assumed business name; it is not the name of the legal entity that owns the company. Do not use a d/b/a to disclose the ownership rights of a legal entity. Complete this section only if the disclosing entity enters into a contract with a collective company or proposes to provide a contract for the provision of services related to the disclosing entity`s participation in HHSC programs. Otherwise, select the NA check box, leave sections 4 through 6 blank, and proceed to section 7.
Directly owned shares are defined as the ownership of shares, equity or interest in the profits of the disclosing company. Indirect holdings are defined as interests in an entity that has direct or indirect interests in the disclosing entity. The amount of indirect ownership of the disclosing entity held by another entity is determined by multiplying the percentage of ownership shares at each level. Indirect ownership must be reported if it corresponds to a 5% or more interest of the disclosing company. If additional entries are required for full disclosure, copy this page and add it as an attachment. The disclosing entity is required to fully disclose all levels of ownership or control of the disclosing entity and is required to disclose all entities and natural persons at each level of ownership, from the ownership of the disclosing entity to the ownership of each subsequent owner company. The disclosing company is also required to disclose all employees above each level of ownership. To determine the ownership interest on a mortgage, trust deed, note or other bond, the percentage of shares held in the bond is multiplied by the percentage of the disclosing entity`s assets used to secure the bond. Example: If A holds 10% of a bond secured by 60% of the assets of the disclosing company, A`s share is equal to 6% and must be reported. If, on the other hand, B holds 40 % of a bond secured by 10 % of the assets of the disclosing entity, B`s share is equal to 4 % and does not need to be reported. An employee manager is defined as a director general, manager, administrator, director general or any other person who exercises operational or management control over an institution, organization or body or who directly or indirectly carries out the day-to-day activities of an institution, organization or body. Select Yes or No to answer both questions.
If both questions are answered Yes, provide the requested information. Note: A secured obligation to a business entity that is a financial institution regulated by a federal or state government does not need to be disclosed. Select Yes or No to answer both questions. If you answer both yes questions, provide the requested information. The disclosing company is also required to fully disclose all persons who have a controlling interest at each level of ownership and all senior managers at each level of ownership. Example: If A holds 10% of the shares of a corporation that owns 80% of the shares of the disclosing corporation, A`s interest corresponds to an indirect interest of 8% and must be reported. Conversely, if B holds 80% of the shares of a company that holds 5% of the shares of the disclosing company, B`s interest corresponds to 4% of the indirect interest of the disclosing company and does not need to be reported. First of all, listed companies with a stake of 5% or more in 2.a. Next, list people with a 5% or more stake in 2.b., followed by all people with control participation and management staff.
If additional entries are required for full disclosure, copy this section and add it as an attachment. Use a separate page for each business unit exposed at any level of the ownership structure. Form 5871 is completed and filed as a condition of approval or renewal of an application for Texas Medicaid registration or a contractual agreement between the disclosing entity (applicant/provider) and the Health and Human Services Commission (HHSC) for a service program. Full and accurate disclosure of ownership and control rights is required. Failure to submit the requested information may result in the rejection of the disclosing entity`s application for registration with Texas Medicaid, participation in HHSC programs, or, if the disclosing entity is already participating, termination of the disclosing entity`s Texas Medicaid registration and contract with HHSC. Based on the first level of ownership information in Section 2, complete the next level of ownership and control interests information. Complete this section for each business unit previously specified in Section 2.a and each subsequent business unit. Legal name of business unit – Enter the legal name of the business entity with a 5% or greater interest in a bond secured by the assets of the disclosing entity. Select Yes or No to indicate whether or not a 100% interest has been disclosed in this section.
If no, select Yes or No to indicate whether or not each of the remaining shareholders owns less than 5%. If not, identify other shareholders who hold a 5% or greater interest, or attach a statement explaining why these shareholders are not disclosed. Complete this section for all natural and legal persons listed in sections 2, 3, 4, 5, 6 or 7.a. or 7.b. If an answer is given to a yes question, provide the requested information. The disclosing entity is required to disclose in full all levels of ownership of 5% or more and to disclose in full all entities and natural persons at each level of ownership, from the ownership of the disclosing entity to the ownership of each subsequent owner business. The participation of 5% or more may be direct, indirect or a combination of direct and indirect ownership shares. Details – Specify how these outstanding commitments will be met. For anyone who has the legal right to work in the United States, attach a copy of the person`s green card, visa, or other documents proving the person`s right to work and reside in the United States.
Physical address (street, city, state, zip code) – Explicit. Provide the name, identification number of the federal taxpayer and the address of all others. . Tax Identification Number (EIN or SSN) – Enter the nine-digit Federal Employer Identification Number (EIN) assigned to the disclosing entity by the Internal Revenue Service. Temporary tax identification numbers are not acceptable. If the disclosing entity is a sole proprietorship or a natural person without a NA, enter the social security number (SSN) of the owner or person. Shares listed on the stock exchange? – Indicate whether the shares of the business unit are listed on the stock exchange. Check NA if there is no need. For example, a for-profit business must enable Yes or No. a general partnership should review the NA. Legal name of the business unit – Enter the legal name of the business unit. For question 8.b., the term “sanction” is defined as recovery, deferral of payment, imposition of penalties or damages, termination of the contract, exclusion, exclusion, suspension, revocation or any other act synonymous […].