• Texas Department of Aging Form 5871


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    • Abstract: Texas Department of Aging Form 5871and Disability Services Disclosure of Ownership and Control Statement February 2012

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Texas Department of Aging Form 5871
and Disability Services Disclosure of Ownership and Control Statement February 2012
Attention! Carefully read all of the instructions to the form before completing this form. Errors and omissions will delay
processing. You may be able to use Form 5871-S, Disclosure of Ownership and Control Statement – Short Form, in
lieu of using this form. See instructions to Form 5871-S to determine if you meet the requirements.
Section 1. Disclosing Entity Information
Legal Name of Disclosing Entity (applicant/provider) Doing Business As (d/b/a), if applicable
Name of Contact Person Title or Relationship to Disclosing Entity
Area Code and Telephone No. Area Code and Fax No. Email Address
Business Entity Type
Sole Proprietor General Partnership Limited Liability Company
For-profit Corporation Publicly Traded Limited Partnership Trust, Living Trust or Estate
Nonprofit Corporation Limited Liability Partnership Other (specify):
Taxpayer Identification No. (EIN or SSN) Provider Identifier No. (NPI or API)
Section 2. Disclosing Entity’s Ownership and Control Interest Information
See Exhibit A of the instructions for a list of required ownership and control interest disclosures by business entity type. Disclose business
entities with an ownership interest in 2.a. and individuals with an ownership or control interest and managing employees in 2.b.
2.a. Business Entity Ownership Interest
Legal Name of Business Entity Business Entity Type Employer Identification No. (EIN)
Physical Address (Street, City, State, ZIP Code) Shares Publicly Traded? Percent of Ownership
Yes No NA
Legal Name of Business Entity Business Entity Type Employer Identification No. (EIN)
Physical Address (Street, City, State, ZIP Code) Shares Publicly Traded? Percent of Ownership
Yes No NA
Legal Name of Business Entity Business Entity Type Employer Identification No. (EIN)
Physical Address (Street, City, State, ZIP Code) Shares Publicly Traded? Percent of Ownership
Yes No NA
2.b. Individual Ownership or Control Interest; Managing Employees
First Name of Individual Last Name MI Jr., Sr., etc.
Social Security No. Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosing Entity Percent of Ownership
Physical Address (Street, City, State, ZIP Code) Driver License No. State
First Name of Individual Last Name MI Jr., Sr., etc.
Social Security No. Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosing Entity Percent of Ownership
Physical Address (Street, City, State, ZIP Code) Driver License No. State
Form 5871
Page 2 / 02-2012
Section 2. Disclosing Entity’s Ownership and Control Interest Information (continued)
2.b. Individual Ownership or Control Interest; Managing Employees (continued)
First Name of Individual Last Name MI Jr., Sr., etc.
Social Security No. Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosing Entity Percent of Ownership
Physical Address (Street, City, State, ZIP Code) Driver License No. State
First Name of Individual Last Name MI Jr., Sr., etc.
Social Security No. Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosing Entity Percent of Ownership
Physical Address (Street, City, State, ZIP Code) Driver License No. State
First Name of Individual Last Name MI Jr., Sr., etc.
Social Security No. Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosing Entity Percent of Ownership
Physical Address (Street, City, State, ZIP Code) Driver License No. State
First Name of Individual Last Name MI Jr., Sr., etc.
Social Security No. Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosing Entity Percent of Ownership
Physical Address (Street, City, State, ZIP Code) Driver License No. State
First Name of Individual Last Name MI Jr., Sr., etc.
Social Security No. Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosing Entity Percent of Ownership
Physical Address (Street, City, State, ZIP Code) Driver License No. State
First Name of Individual Last Name MI Jr., Sr., etc.
Social Security No. Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosing Entity Percent of Ownership
Physical Address (Street, City, State, ZIP Code) Driver License No. State
First Name of Individual Last Name MI Jr., Sr., etc.
Social Security No. Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosing Entity Percent of Ownership
Physical Address (Street, City, State, ZIP Code) Driver License No. State
2.c. For for-profit corporations only
Has 100% ownership interest been disclosed in Section 2.a and 2.b? ................................................................................ Yes No
If No, does each of the remaining shareholders (entities and individuals) own less than 5%? ........................................... Yes No
If No, disclose remaining shareholders that have a 5% or more ownership interest or attach an explanation why these
shareholders are not disclosed.
Copy this page to use as an attachment if more entries are required.
Form 5871
Page 3 / 02-2012
Section 3. Disclosing Entity’s Ownership and Control Interest Information: Next Level(s)
See Exhibit A of the instructions for a list of required ownership and control interest disclosures by business entity type. Disclose business
entities with an ownership interest in 3.a. and individuals with an ownership or control interest and managing employees in 3.b.
Legal Name of Business Entity Disclosed on This Page
Section 3.a. Business Entity Ownership Interest
Legal Name of Business Entity Business Entity Type Employer Identification No.
(EIN)
Physical Address (Street, City, State, ZIP Code) Shares Publicly Traded? Percent of Ownership
Yes No NA
Legal Name of Business Entity Business Entity Type Employer Identification No.
(EIN)
Physical Address (Street, City, State, ZIP Code) Shares Publicly Traded? Percent of Ownership
Yes No NA
Legal Name of Business Entity Business Entity Type Employer Identification No.
(EIN)
Physical Address (Street, City, State, ZIP Code) Shares Publicly Traded? Percent of Ownership
Yes No NA
Section 3.b. Individual Ownership or Control Interest; Managing Employees
First Name of Individual Last Name MI Jr., Sr., etc.
Social Security No. Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity Percent of Ownership
Physical Address (Street, City, State, ZIP Code) Driver License No. State
First Name of Individual Last Name MI Jr., Sr., etc.
Social Security No. Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity Percent of Ownership
Physical Address (Street, City, State, ZIP Code) Driver License No. State
First Name of Individual Last Name MI Jr., Sr., etc.
Social Security No. Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity Percent of Ownership
Physical Address (Street, City, State, ZIP Code) Driver License No. State
First Name of Individual Last Name MI Jr., Sr., etc.
Social Security No. Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity Percent of Ownership
Physical Address (Street, City, State, ZIP Code) Driver License No. State
Copy this page to use as an attachment if more entries are required.
Form 5871
Page 4 / 02-2012
Section 3. Disclosing Entity’s Ownership and Control Interest Information: Next Level(s) (continued)
Section 3.b. Individual Ownership or Control Interest; Managing Employees (continued)
First Name of Individual Last Name MI Jr., Sr., etc.
Social Security No. Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity Percent of Ownership
Physical Address (Street, City, State, ZIP Code) Driver License No. State
First Name of Individual Last Name MI Jr., Sr., etc.
Social Security No. Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity Percent of Ownership
Physical Address (Street, City, State, ZIP Code) Driver License No. State
First Name of Individual Last Name MI Jr., Sr., etc.
Social Security No. Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity Percent of Ownership
Physical Address (Street, City, State, ZIP Code) Driver License No. State
First Name of Individual Last Name MI Jr., Sr., etc.
Social Security No. Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity Percent of Ownership
Physical Address (Street, City, State, ZIP Code) Driver License No. State
First Name of Individual Last Name MI Jr., Sr., etc.
Social Security No. Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity Percent of Ownership
Physical Address (Street, City, State, ZIP Code) Driver License No. State
First Name of Individual Last Name MI Jr., Sr., etc.
Social Security No. Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity Percent of Ownership
Physical Address (Street, City, State, ZIP Code) Driver License No. State
3.c. For for-profit corporations only
Has 100% ownership interest been disclosed in Section 3.a and 3.b? ................................................................................ Yes No
If No, does each of the remaining shareholders (entities and individuals) own less than 5%? ............................................ Yes No
If No, disclose remaining shareholders that have a 5% or more ownership interest or attach an explanation why these
shareholders are not disclosed.
Copy this page to use as an attachment if more entries are required.
Form 5871
Page 5 / 02-2012
Note: If the disclosing entity does not contract or propose to contract with a management company to perform any services related
to its participation in DADS programs, leave sections 4 through 6 blank and go to Section 7.
Section 4. Management Company Information
Legal Name of Business Entity Business Entity Type Employer Identification No. (EIN)
Physical Address (Street, City, State, ZIP Code)
Mailing Address (P.O. Box or Street, City, State, ZIP Code), if different
Name of Contact Person Title or Relationship to Management Company
Area Code and Telephone Area Code and Fax No. Email Address
No.
Section 5. Management Company’s Ownership and Control Interest Information
See Exhibit A of the instructions for a list of required ownership and control interest disclosures by business entity type. Disclose business
entities with an ownership interest in 5.a. and individuals with an ownership or control interest and managing employees in 5.b.
Section 5.a. Business Entity Ownership Interest
Legal Name of Business Entity Business Entity Type Employer Identification No. (EIN)
Physical Address (Street, City, State, ZIP Code) Shares Publicly Traded? Percent of Ownership
Yes No NA
Legal Name of Business Entity Business Entity Type Employer Identification No. (EIN)
Physical Address (Street, City, State, ZIP Code) Shares Publicly Traded? Percent of Ownership
Yes No NA
Legal Name of Business Entity Business Entity Type Employer Identification No. (EIN)
Physical Address (Street, City, State, ZIP Code) Shares Publicly Traded? Percent of Ownership
Yes No NA
Section 5.b. Individual Ownership or Control Interest; Managing Employees
First Name of Individual Last Name MI Jr., Sr., etc.
Social Security No. Date of Birth (mm/dd/yyyy) Title or Position Held with Management Company Percent of Ownership
Physical Address (Street, City, State, ZIP Code) Driver License No. State
First Name of Individual Last Name MI Jr., Sr., etc.
Social Security No. Date of Birth (mm/dd/yyyy) Title or Position Held with Management Company Percent of Ownership
Physical Address (Street, City, State, ZIP Code) Driver License No. State
First Name of Individual Last Name MI Jr., Sr., etc.
Social Security No. Date of Birth (mm/dd/yyyy) Title or Position Held with Management Company Percent of Ownership
Physical Address (Street, City, State, ZIP Code) Driver License No. State
Copy this page to use as an attachment if more entries are required.
Form 5871
Page 6 / 02-2012
Section 5. Management Company’s Ownership and Control Interest Information (continued)
Section 5.b. Individual Ownership or Control Interest; Managing Employees (continued)
First Name of Individual Last Name MI Jr., Sr., etc.
Social Security No. Date of Birth (mm/dd/yyyy) Title or Position Held with Management Company Percent of Ownership
Physical Address (Street, City, State, ZIP Code) Driver License No. State
First Name of Individual Last Name MI Jr., Sr., etc.
Social Security No. Date of Birth (mm/dd/yyyy) Title or Position Held with Management Company Percent of Ownership
Physical Address (Street, City, State, ZIP Code) Driver License No. State
First Name of Individual Last Name MI Jr., Sr., etc.
Social Security No. Date of Birth (mm/dd/yyyy) Title or Position Held with Management Company Percent of Ownership
Physical Address (Street, City, State, ZIP Code) Driver License No. State
First Name of Individual Last Name MI Jr., Sr., etc.
Social Security No. Date of Birth (mm/dd/yyyy) Title or Position Held with Management Company Percent of Ownership
Physical Address (Street, City, State, ZIP Code) Driver License No. State
First Name of Individual Last Name MI Jr., Sr., etc.
Social Security No. Date of Birth (mm/dd/yyyy) Title or Position Held with Management Company Percent of Ownership
Physical Address (Street, City, State, ZIP Code) Driver License No. State
First Name of Individual Last Name MI Jr., Sr., etc.
Social Security No. Date of Birth (mm/dd/yyyy) Title or Position Held with Management Company Percent of Ownership
Physical Address (Street, City, State, ZIP Code) Driver License No. State
First Name of Individual Last Name MI Jr., Sr., etc.
Social Security No. Date of Birth (mm/dd/yyyy) Title or Position Held with Management Company Percent of Ownership
Physical Address (Street, City, State, ZIP Code) Driver License No. State
5.c. For for-profit corporations only
Has 100% ownership interest been disclosed in Section 5.a and 5.b? ................................................................................ Yes No
If No, does each of the remaining shareholders (entities and individuals) own less than 5%? ............................................ Yes No
If No, disclose remaining shareholders that have a 5% or more ownership interest or attach an explanation why these
shareholders are not disclosed.
Copy this page to use as an attachment if more entries are required.
Form 5871
Page 7 / 02-2012
Section 6. Management Company’s Ownership and Control Interest Information: Next Level(s)
See Exhibit A of the instructions for a list of required ownership and control interest disclosures by business entity type. Disclose business
entities with an ownership interest in 6.a. and individuals with an ownership or control interest and managing employees in 6.b.
Legal Name of Business Entity Disclosed on This Page
Section 6.a. Business Entity Ownership Interest
Legal Name of Business Entity Business Entity Type Employer Identification No. (EIN)
Physical Address (Street, City, State, ZIP Code) Shares Publicly Traded? Percent of Ownership
Yes No NA
Legal Name of Business Entity Business Entity Type Employer Identification No. (EIN)
Physical Address (Street, City, State, ZIP Code) Shares Publicly Traded? Percent of Ownership
Yes No NA
Legal Name of Business Entity Business Entity Type Employer Identification No. (EIN)
Physical Address (Street, City, State, ZIP Code) Shares Publicly Traded? Percent of Ownership
Yes No NA
Section 6.b. Individual Ownership or Control Interest; Managing Employees
First Name of Individual Last Name MI Jr., Sr., etc.
Social Security No. Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity Percent of Ownership
Physical Address (Street, City, State, ZIP Code) Driver License No. State
First Name of Individual Last Name MI Jr., Sr., etc.
Social Security No. Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity Percent of Ownership
Physical Address (Street, City, State, ZIP Code) Driver License No. State
First Name of Individual Last Name MI Jr., Sr., etc.
Social Security No. Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity Percent of Ownership
Physical Address (Street, City, State, ZIP Code) Driver License No. State
First Name of Individual Last Name MI Jr., Sr., etc.
Social Security No. Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity Percent of Ownership
Physical Address (Street, City, State, ZIP Code) Driver License No. State
First Name of Individual Last Name MI Jr., Sr., etc.
Social Security No. Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity Percent of Ownership
Physical Address (Street, City, State, ZIP Code) Driver License No. State
Copy this page to use as an attachment if more entries are required.
Form 5871
Page 8 / 02-2012
Section 6. Management Company’s Ownership and Control Interest Information: Next Level(s) (continued)
Section 6.b. Individual Ownership or Control Interest; Managing Employees (continued)
First Name of Individual Last Name MI Jr., Sr., etc.
Social Security No. Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity Percent of Ownership
Physical Address (Street, City, State, ZIP Code) Driver License No. State
First Name of Individual Last Name MI Jr., Sr., etc.
Social Security No. Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity Percent of Ownership
Physical Address (Street, City, State, ZIP Code) Driver License No. State
First Name of Individual Last Name MI Jr., Sr., etc.
Social Security No. Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity Percent of Ownership
Physical Address (Street, City, State, ZIP Code) Driver License No. State
First Name of Individual Last Name MI Jr., Sr., etc.
Social Security No. Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity Percent of Ownership
Physical Address (Street, City, State, ZIP Code) Driver License No. State
First Name of Individual Last Name MI Jr., Sr., etc.
Social Security No. Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity Percent of Ownership
Physical Address (Street, City, State, ZIP Code) Driver License No. State
First Name of Individual Last Name MI Jr., Sr., etc.
Social Security No. Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity Percent of Ownership
Physical Address (Street, City, State, ZIP Code) Driver License No. State
First Name of Individual Last Name MI Jr., Sr., etc.
Social Security No. Date of Birth (mm/dd/yyyy) Title or Position Held with Disclosed Entity Percent of Ownership
Physical Address (Street, City, State, ZIP Code) Driver License No. State
6.c. For for-profit corporations only
Has 100% ownership interest been disclosed in Section 6.a and 6.b? ................................................................................ Yes No
If No, does each of the remaining shareholders (entities and individuals) own less than 5%? ............................................ Yes No
If No, disclose remaining shareholders that have a 5% or more ownership interest or attach an explanation why these
shareholders are not disclosed.
Copy this page to use as an attachment if more entries are required.
Form 5871
Page 9 / 02-2012
Section 7. Other Ownership and Control Interest Information
7.a. Does any business entity or individual have a 5% or greater ownership interest in any mortgage, deed of trust,
note or other obligation secured by the disclosing entity? ............................................................................................. Yes No
If yes, does the business entity’s or individual’s ownership interest equal at least 5% of the value of the disclosing
entity’s property or assets? ........................................................................................................................................... Yes No
If yes, compete the following for the business entity or individual. 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.
Legal Name of Business Entity Employer Identification No. (EIN)
Physical Address (Street, City, State, ZIP Code)
Legal Name of Business Entity Employer Identification No. (EIN)
Physical Address (Street, City, State, ZIP Code)
Name of Individual Social Security No. Date of Birth (mm/dd/yyyy)
Physical Address (Street, City, State, ZIP Code) Driver License No. State
Name of Individual Social Security No. Date of Birth (mm/dd/yyyy)
Physical Address (Street, City, State, ZIP Code) Driver License No. State
7.b. Does the disclosing entity have a 5% or greater ownership interest in any subcontractor? .......................................... Yes No
If yes, will the subcontractor perform any services related to the disclosing entity’s participation in
DADS programs? .......................................................................................................................................................... Yes No
If yes, compete the following for the subcontractor.
Legal Name of Business Entity (Subcontractor) Business Entity Type Employer Identification No. (EIN)
Physical Address (Street, City, State, ZIP Code) Disclosing Entity’s Percentage of Ownership in Subcontractor
Provide the name, federal taxpayer ID number and address of all other individuals or business entities that have a 5% or more ownership
interest or control interest in the subcontractor listed above.
Name of Individual or Business Entity SSN or EIN Physical Address (Street, City, State, ZIP Code)
Name of Individual or Business Entity SSN or EIN Physical Address (Street, City, State, ZIP Code)
Name of Individual or Business Entity SSN or EIN Physical Address (Street, City, State, ZIP Code)


Use: 0.0686