Common use of Ownership and control information Clause in Contracts

Ownership and control information. (a) List the name, title, address, and SSN for each office and/or individual who has direct or indirect ownership or controlling interest, separately or in combination, amounting to an ownership interest of 5% or more of the provider entity. List the name, Tax ID (TIN), and address of any organization, corporation, or entity having direct or indirect ownership or controlling interest, separately or in combination, amounting to an ownership interest of 5% or more in the provider entity. Attach additional pages as necessary to list all officers, owners, management and ownership entities. Name Title Address SSN/TIN Percentage (b) List those persons named in Item II (a) that are related to each other (spouse, parent, child, or sibling). Name Relationship SSN (c) List the name, title, address and social security number of each person with an ownership or control interest in any subcontractor in which the disclosing entity has direct or indirect ownership of 5% or more. Name Title Address SSN Percentage (d) List the name, address and TIN of any other disclosing entity in which a person with an ownership or controlling interest in the disclosing entity also has an ownership or control interest of at least 5% or more. Name Title Address SSN Percentage Oklahoma Health Care Authority (a) List the name, title, SSN and address of each officer and/or individual who has ownership or control interest in the disclosing entity, or is an agent or managing employee of the disclosing entity and has been convicted of a criminal offense related to that person’s involvement in any program under Medicare, Medicaid or the Title XX services program since the inception of those programs. Name Title Address SSN (or TIN if organization) (b) List the name, title, social security number and address of any individual who has an ownership or controlling interest in the disclosing entity and has been suspended or debarred from participation in Medicare, Medicaid or Title XX program since the inception of those programs. Name Title Address SSN

Ownership and control information. (a) List the name, title, address, and SSN for each office and/or individual who has direct or indirect ownership or controlling interest, separately or in combination, amounting to an ownership interest of 5% or more of the provider entity. List the name, Tax ID (TIN), and address of any organization, corporation, or entity having direct or indirect ownership or controlling interest, separately or in combination, amounting to an ownership interest of 5% or more in the provider entity. Attach additional pages as necessary to list all officers, owners, management and ownership entities. Name Title Address SSN/TIN Percentage (b) List those persons named in Item II (a) that are related to each other (spouse, parent, child, or sibling). Name Relationship SSN (c) List the name, title, address and social security number of each person with an ownership or control interest in any subcontractor in which the disclosing entity has direct or indirect ownership of 5% or more. Name Title Address SSN Percentage (d) List the name, address and TIN of any other disclosing entity in which a person with an ownership or controlling interest in the disclosing entity also has an ownership or control interest of at least 5% or more. Name Title Address SSN Percentage Oklahoma Health Care AuthorityPercentage (a) List the name, title, SSN and address of each officer and/or individual who has ownership or control interest in the disclosing entity, or is an agent or managing employee of the disclosing entity and has been convicted of a criminal offense related to that person’s involvement in any program under Medicare, Medicaid or the Title XX services program since the inception of those programs. Name Title Address SSN (or TIN if organization) (b) List the name, title, social security number and address of any individual who has an ownership or controlling interest in the disclosing entity and has been suspended or debarred from participation in Medicare, Medicaid or Title XX program since the inception of those programs. Name Title Address SSN

Ownership and control information. (a) List the name, title, address, and SSN for each office officer and/or individual who has direct or indirect ownership or controlling interest, separately or in combination, amounting to an ownership interest of 5% or more of the provider entity. List the name, Tax ID (TINTIN ), and address of any organization, corporation, or entity having direct or indirect ownership or controlling interest, separately or in combination, amounting to an ownership interest of 5% or more in the provider entity. Attach additional pages as necessary to list all officers, owners, management and ownership entities. Name Title Address SSN/TIN Percentage (b) List those persons named in Item II (a) that are related to each other (spouse, parent, child, or sibling). Name Relationship SSN (c) List the name, title, address and social security number of each person with an ownership or control interest in interestin any subcontractor in which the disclosing entity has direct or indirect ownership of 5% 5 percent or more. Name Title Address SSN Percentage (d) List the name, address and TIN of any other disclosing entity in which a person with an ownership or controlling interest in the disclosing entity also has an ownership or control interest of at least 5% or more. Name Title Address SSN Percentage Oklahoma Health Care AuthorityTIN Percentage (a) List the name, title, SSN and address of each officer and/or individual who has ownership or control interest in the disclosing entity, or is an agent or managing employee of the disclosing entity and has been convicted of a criminal offense related to that person’s 's involvement in any program under Medicare, Medicaid or the Title XX services program since the inception of those programs. Name Title Address SSN (or TIN if organization) (b) List the name, title, social security number and address of any individual who has an ownership or controlling interest in the disclosing entity and has been suspended or debarred from participation in Medicare, Medicaid or Title XX program since the inception of those programs. Name Title Address SSN