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<br /> fl/ II <br /> £+et at'bMnt of fofeafth and Human Services Form Approved <br /> H~ .m CÄre Financing Administration OMB No. 0938-0086 <br /> IV. (a) Has there been a change in ownershIp or rontrol within the last year'? ~NO <br /> If yes. give date ' LB8 <br /> (b) Do you anticipate any change of ~ « ~ Wtthio the year? æ::JiJ No LB9 <br /> If yes. when? <br /> (c) Do you anticipate filing for bankruptcy within the year? ~NO LB10 <br /> If yes. when? <br /> V. Is tnis facility operated by a management company. or leased in whole or part by another organization? -~'f\ o' <br /> If yes. gIve date of change in oper<rtions . . . . - LB11 <br /> <br /> VI. Has there been a change in AdminisUatoc. Director of Nursing or Medical Director within the last year? ~NO <br /> LB12 <br /> VIto (a). Is this facility cham affiliated? (ff yes. Ii$ name. address 01 CorporatIOn. and aN) . D Yes ~ No <br /> Name' EIN 1/ lB13 <br /> A.ddress <br /> LB14 <br /> VII. (b) If the answer to Question VILa. is No. was the facility ever affiliated with a chain? <br /> (If YES. list Name. Address of Corporation and ErN) DYes ~ No <br /> Name EIN N LB18 <br /> Address <br /> lB19 <br /> VIII. Have you increased your bed capacity by 10% or more or by 10 beds, whichever is greater, within the last 2 Y9.ars? <br /> DYes ~ No lB15 <br /> If yes. give year of change <br /> Current beds LB16 Prior beds LB17 <br /> <br /> NHOEVER KNOWINGLY AND WILLFULLY MAKES OR CAUSES TO BE MADE A FALSE STATEMENT OR REPRESENTA:rION OF THIS STATEMENT. <br /> YAY BE PROSECUTED UNDER APPLICABLE FEDERAL OR STATE LAWS. IN ADDITION, KNOWINGLY AND WILLFULLY FAILING TO FULLY AND <br /> <\CCURATELY DISCLOSE THE INFORMATION REOUESTED MAY RESULT IN DENIAL OF A REQUEST TO PARTICIPATE OR WHERE THE ENTITY <br /> A.LREADY PARTICIPATES. A TERMINATION OF ITS AGREEMENT OR CONTRACT WITH THE STATE AGENCY OR THE SECRETARY. AS <br /> ~PPROPRIATE. <br /> c'lame of Authorized Representative (Typed) Title <br /> Larry D. Gilley City Manager <br /> - <br /> 3ignat , Date <br /> 12/14/93 <br /> ~emarks <br /> - --- <br />