Form 5871

A full and accurate disclosure of ownership and control interest is required. See full list on hhs. If an individual, enter the individual’s full legal name. Name of Contact Person– Enter the name of the person who can answer questions about the information furnished on the form.

Area Code and Fax No. Email Address – Self-exp. The disclosing entity is required to fully disclose all levels of ownership of or more, and to fully disclose all entities and all individuals at each level of ownership, from the ownership of the disclosing entity to the ownership of each successive ownership entity. The or more ownership interest may be direct, indirect or a combination of direct and indirect ownership interest. Direct ownership interest is defined as the possession of stock, equity in capital or any interest in the profits of the disclosing entity.

Indirect ownership interest is defined as ownership interest in an entity that has direct or indirect ownership interest in the disclosing entity. The amount of indirect ownership in the disclosing entity that is held by any other entity is determined by multiplying the percentage of ownership interest at each level. An indirect ownership must be reported if it equates to an ownership interest of or more of the disclosing entity.

Example:If A owns of the s. Otherwise, check the NA box, leave sections 4-blank and go to Section 7. For example, for profit-corporation, limited partnership, limited liability company, etc. Business Entity Type– Enter the applicable business entity type. Employer Identification Number (EIN)– Enter the federal employer identification number (EIN) assigned to the management company by the IRS.

Physical Address (Street, City, State, ZIP Code)– Self-explanatory. Mailing Address (P.O. Box or Street, City, State, ZIP Code)– Self-explanatory. The disclosing entity is also required to disclose all managing employees at each level of ownership. Complete this section if Section was completed.

First, list business entities with a or more ownership interest in 5. Then, list individuals with a or more ownership interest in 5. If additional entries are required for full disclosure, copy this section and include as an attachment. If both questions are answered Yes, provide the requested information. 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. If any question is answered Yes, provide the information requested.

A judgment of conviction has been entered against an individual or entity by a federal, state or local court, regardless of whether: 1. An individual or entity has entered into participation in a first offender, deferred adjudication or other program or arrangement where judgment of conviction has been withheld. The advanced tools of the editor will lead you through the editable PDF template. Enter your official identification and contact details. Get the quality you expect from Avery , the world’s largest supplier of labels. Advance Directives Health and Human Services Forms.

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Total ownership should equal 1percent unless otherwise noted in the instructions. If ownership does not total 1percent, the provider must submit a letter explaining the discrepancy. Utilize a check mark to point the choice where demanded.

Persons With Respect To Certain Foreign Corporations, including recent updates, related forms, and instructions on how to file. Includes utility rack with soaking cup, colander with cutting boar and sink rack.