ࡱ> _ bjbj r=\r=\Q-g 88888D|||\|*jL::::@z T!*******$],/8*u8#::##8*88::*6)6)6)#8:8:*6)#*6)6)6):p2Ov%6))*0*6)/'/6)/86)z">",6)"$#z"z"z"8*8*(Xz"z"z"*####/z"z"z"z"z"z"z"z"z" > : Completion and submission of this form is a condition of participation, certification, or recertification under any of the programs established by Titles V, XVIII, XIX, and XX, or as a condition of approval or renewal of a contractor agreement between the disclosing entity and the secretary of appropriate state agency under any of the above-titled programs, a full and accurate disclosure of ownership and financial interest is required. Failure to submit requested information may result in a refusal by the Secretary or appropriate State agency to enter into an agreement or contract with any such institution or in termination of existing agreements. Special Instructions for Title XX Providers All Title XX providers must complete Part II (a) and (b) of this form. Only those Title XX providers rendering medical, remedial, or health-related homemaker services must complete Parts II and III. Title V providers must complete Parts II and III. Please answer all questions as of the current date. If the yes block for any item is checked, list requested additional information under the Remarks Section on page 2, referencing the item number to be continued. If additional space is needed use an attached sheet. These instructions are designed to clarify certain questions on the form. Instructions are listed in question order for easy reference. No instructions have been given for questions considered self-explanatory. It is essential that all applicable questions be answered accurately and that all information be current. Item I(a) Under identifying information specify in what capacity the entity is doing business as (DBA), example, name of trade or corporation. (b) For Regional Office Use Only. If the yes box is checked for Item VII the Regional Office will enter the 5-digit number assigned by HCFA to chain organizations. Item IISelf-explanatory Item IIIList the names of all individuals and organizations having direct or indirect ownership interests, or controlling interest separately or in combination amounting to an ownership interest of 5 percent or more in the disclosing entity. Direct ownership interest is defined as the possession of stock, equity in capital or any interest in the profits of the disclosing entity. A disclosing entity is defined as a Medicare provider or supplier, or other entity that furnishes services or arranges for furnishing services under Medicaid or the Maternal and Child Health program, or health related services under the social services program. Indirect ownership interest is defined as ownership interest in an entity that has direct or indirect ownership 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 interest must be reported if it equates to an ownership interest of 5 percent or more in the disclosing entity. Example: if A owns 10 percent of the stock in a corporation that owns 80 percent of the stock of the disclosing entity, A's interest equates to an 8 percent indirect ownership and must be reported. Controlling interest is defined as the operational direction or management of a disclosing entity which may be maintained by any or all of the following devices: the ability or authority, expressed or reserved, to amend or change the corporate identity (e.g., joint venture agreement, unincorporated business status) of the disclosing entity; the ability or the authority to nominate or name members of the Board of Directors or Trustees of the disclosing entity; the ability or authority, expressed or reserved, to amend or change the by-laws, constitution, or other operating or management direction of the disclosing entity; the right to control any or all of the assets or other property of the disclosing entity upon the sale or dissolution of that entity; the ability or authority, expressed or reserved, to control the sale of any or all of the assets, to encumber such assets by way of mortgage or other indebtedness; to dissolve the entity, or to arrange for the sale or transfer of the disclosing entity to new ownership or control. Items IV-VIIChanges in Provider Status Change in provider status is defined as any change in management control. Examples of such changes would include: a change in medical or Nursing Director, a new Administrator, contracting the operation of the facility to a management corporation, a change in the composition of the owning partnership which under applicable state law is not considered a change in ownership, or the hiring or dismissing any employees with 5 percent or more financial interest in the facility or in an owning corporation, or any change of ownership. For Items IV-VII, if the yes box is checked, list additional information requested under Remarks. Clearly identify which item is being continued. Item IV(a & b) If there has been a change in ownership within the last year or if you anticipate a change, indicate the date in the appropriate space. Item VIf the answer is yes, list name of the management firm and employer identification number (EIN), or the name of the leasing organization. A management company is defined as any organization that operates and manages a business on behalf of the owner of that business, with the owner retaining ultimate legal responsibility for operation of the facility. Item VIIf the answer is yes, identify which has changed (Administrator, Medical Director, or Director of Nursing) and the date the change was made. Be sure to include name of the new Administrator, Director of Nursing, or Medical Director as appropriate. Item VIIA chain affiliate is any free-standing health care facility that is owned, controlled, or operated under lease or contract by an organization consisting of two or more free-standing health care facilities organized within or across state lines which is under the ownership or through any other device, control, and direction of a common party. Chain affiliates include such facilities whether public, private, charitable, or proprietary. They also include subsidiary organizations and holding corporations. Provider-based facilities, such as hospital-based home health agencies, are not considered to be chain affiliates. Item VIIIIf yes, list the actual number of beds in the facility now and the previous number. I.Identifying Information(a)Name of Entity  FORMTEXT      Provider No.  FORMTEXT      Vendor No.  FORMTEXT      Phone  FORMTEXT      DBA  FORMTEXT      Street Address  FORMTEXT      City  FORMTEXT      County  FORMTEXT      State  FORMTEXT      Zip  FORMTEXT      II.Answer the following questions by marking  Yes or  No. If any of the questions are answered  Yes, list names and address of individuals or corporations under Remarks on Page 2. Identify each item number to be continued.(a)Are there any individuals or organizations having a direct or indirect ownership or control interest of 5% or more in the institution, organization, or agency that have been convicted of a criminal offense related to the involvement of such person, or organizations in any of the programs established by Titles XVIII, XIX, or XX?  FORMCHECKBOX  Yes  FORMCHECKBOX  No(b)Are there any directors, officers, agents, or managing employees of the institution, agency, or organization who have ever been convicted of a criminal offense related to their involvement in such programs established by Title XVIII, XIX, or XX?  FORMCHECKBOX  Yes  FORMCHECKBOX  No(c)Are there any individuals currently employed by the institution, agency, or organization in a managerial, accounting, auditing, or similar capacity who were employed by the institutions, organizations, or agencys fiscal intermediary or carrier within the previous 12 months? (Title XVIII providers only.)  FORMCHECKBOX  Yes  FORMCHECKBOX  NoIII.(a)List names and addresses for individuals, or the EIN for organizations having direct or indirect ownership or a controlling interest in the entity. List any additional names and addresses under Remarks on Page 2. If more than one individual is reported and any of these persons are related to each other, this must be reported under Remarks on Page 2.NAMEADDRESSEIN  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT      (b)Type of entity:  FORMCHECKBOX  Sole Proprietorship  FORMCHECKBOX  Partnership  FORMCHECKBOX Unincorporated Associations  FORMCHECKBOX  Corporation  FORMCHECKBOX  Other (specify:  FORMTEXT )(c)If the disclosing entity is a corporation, list names and addresses of the Directors and EINs for Corporations under Remarks on Page 2.(d)Are any owners of the disclosing entity also owners of other Medicare/Medicaid facilities? (Example: sole proprietor, partnership, or members of Board of Directors.)  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, list names, addresses of individuals and provider numbers.NAMEADDRESSEIN  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       IV. (a) Has there been a change in ownership or control within the last year?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, give the date.  FORMTEXT (b) Do you anticipate any change of ownership or control within the year?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, when?  FORMTEXT (c) Do you anticipate filing for bankruptcy within the year?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, when?  FORMTEXT  V.Is this facility operated by a management company, or leased in whole or part by another organization?  FORMCHECKBOX  Yes  FORMCHECKBOX  No VI.Has there been a change in Administrator, Director of Nursing, or Medical Director within the last year?  FORMCHECKBOX  Yes  FORMCHECKBOX  No VII.If this facility is chain affiliated, list name and address of Corporation and EIN.NAMEADDRESSEIN  FORMTEXT    &F9@S[[\oz{¾wwoocWoOoOoh uhCJaJh7Dh uh5CJaJh7Dhl5CJaJhlCJaJh7Dh4!*5CJaJh7DCJaJhCJaJh7Dh5CJaJh4!*CJaJh7DhG;CJaJhGhGCJaJhGh4Qh8,whZ;~CJaJh8,wh4QCJaJh8,wh4Q5;CJaJhlh4QCJaJhGh4QCJaJ YPPPP  !gd4Qnkd$$IflD%D% t0644 lalp yt8,w !$Ifgd8,wl $ !$Ifa$gd8,wl  ! 89RSFG\o?@BCCD  !gd4Q@GCJDL !!!5!6!;!J!K!U!V!" " ""("*">"@"B"L"N"P"f"h"|"~""ȿ~qj'hQ[CJUjhQ[CJUjhQ[CJUmHnHuj?hQ[CJUjhQ[CJU hQ[CJH* hQ[CJhQ[5CJ\hQ[CJaJh7Dhh5CJaJhhCJaJhZ;~CJaJh7Dh uh5CJaJh uhCJaJ, !!5!6!7!;!dSB$ !$Ifa$gd:L$ !$Ifa$gd:Lwkd$$Ifl40$t"0$4 laf4yt:L <<$Ifgd:L <<$Ifgd:L  !gd4Q;!J!"("P"f"""" !<$Ifgd:L <$Ifgd:L $Ifgd:L <$Ifgd:L""""""""""""""""""""##.#0#2#<#>#@#J#L#`#b#d#n#p#r####################jyhQ[CJUjhQ[CJUjhQ[CJUjhQ[CJUjhQ[CJUjhQ[CJU hQ[CJH* hQ[CJjhQ[CJUjhQ[CJUmHnHu6"""";/$ <$Ifgd:L $$Ifa$gd:Lkd$$Ifl4ֈ8x$@ T0$4 laf4yt:L""""#@#J#r###~mbRR !<$Ifgd:L <$Ifgd:L$ !$Ifa$gd:Lwkds$$Ifl408$X 0$4 laf4yt:L $Ifgd:L #### $ $Ifgd:L !<$Ifgd:L###$ $$$N$$4%%<'='K'L'M'T'U'c'd'e'''e(f(t(u(v(}(~(((()))))))))))))*ҶҩҜҏ҂uj hQ[CJUj- hQ[CJUj hQ[CJUjc hQ[CJUj hQ[CJUj hQ[CJU hCJhQ[5CJ\ hQ[CJjhQ[CJUmHnHujhQ[CJUjhQ[CJU. $$$;2 $Ifgd:Lkdc$$Ifl4ֈ8 ~$ s{0$4 laf4yt:L$$$% <<$Ifgd:LdkdS$$Ifl4$$0$4 laf4yt:L%%%%<'i'yk`S <<$Ifgd:L <$Ifgd:L$<$Ifa$gd:L$<$Ifa$gd:Lwkd$$Ifl40$t"0$4 laf4yt:Li'j'k'o'e((tfXM@ <<$Ifgd:L <$Ifgd:L$<$Ifa$gd:L$<$Ifa$gd:Lkd $$Ifl4F8$X 0$    4 laf4yt:L(((())tfXM@ <<$Ifgd:L <$Ifgd:L$<$Ifa$gd:L$<$Ifa$gd:LkdK $$Ifl4F8$X 0$    4 laf4yt:L)))tk $Ifgd:Lkd$$Ifl4F8$X 0$    4 laf4yt:L))**e+}lH<<$If^Hgd:L$<<$Ifa$gd:L <<$Ifgd:Ldkd$$Ifl4$$0$4 laf4yt:L*****p****y+z+++, , ,,,&,(,*,4,6,8,:,<,P,R,T,^,`,b,f,h,|,~,,,,,,,,,,,,,,,ޮޞގ~jMh5ThJ6CJUjh5ThJ6CJUjh5ThJ6CJUjOh5ThJ6CJUjh5TCJUmHnHujh5ThJ6CJU h5TCJjh5TCJU hCJ hYCJ hQ[CJ1e+f+k+s+w+tkkk $Ifgd:Lkdw$$Ifl4F8$X 0$    4 laf4yt:Lw+x+y+,,8,:,b,tkkkkkk $Ifgd:Lkd=$$Ifl4F,$^  0$    4 laf4yt:Lb,d,f,,,,,,tkkkkkk $Ifgd:Lkd;$$Ifl4F,$^  0$    4 laf4yt:L,,,,,,,,,,- - ---&-(-*-4-6-8-:-<-P-R-T-^-`-b----------- . ..ϹϩϙɏɂɏuɏjUhQ[CJUjhQ[CJUjhQ[CJUjh5ThJ6CJUjKh5ThJ6CJUjh5ThJ6CJU hQ[CJ h5TCJjh5TCJUmHnHujh5TCJUjh5ThJ6CJU),,,--8-:-b-tkkkkkk $Ifgd:Lkd9$$Ifl4F,$^  0$    4 laf4yt:Lb-d-f-n--8.tfXM: l D<<$Ifgd:L <$Ifgd:L$<$Ifa$gd:L$<$Ifa$gd:Lkd7$$Ifl4F,$^  0$    4 laf4yt:L...8.9.G.H.I.V.W.e.f.g.x.y......./(/)/e/g/$0&0B0D0F0T0V0r0t0v0 101⼵␊⊀sfjWhYCJUjhYCJUjhYCJU hYCJ hCJh5T>*CJmHnHu"j%h5ThJ6>*CJU h5T>*CJjh5T>*CJUjhQ[CJUj=hQ[CJU hQ[CJjhQ[CJUjhQ[CJU%8.....f/cUG< <$IfgdY$<$Ifa$gd:L$<$Ifa$gd:Lkd;$$Ifl4F8$X 0$    4 laf4yt:L l <<$Ifgd:Lf/g/h/l/$01tfXMM <$IfgdY$<$Ifa$gd:L$<$Ifa$gd:Lkd$$Ifl4F8$X 0$    4 laf4yt:L1 11$1,1tkkk $Ifgd:Lkd$$Ifl4F8$X 0$    4 laf4yt:L,1.101X1Z1111tkkkkkk $Ifgd:Lkd$$Ifl4F,$^  0$    4 laf4yt:L0121F1H1J1T1V1Z1\1p1r1t1~1111111111111111111111112222222(2*2,20222yj%!h5ThJ6CJUj h5ThJ6CJUj9 h5ThJ6CJUj'h5ThJ6CJUjh5ThJ6CJU hQ[CJjh5TCJUmHnHuj;h5ThJ6CJU h5TCJjh5TCJU/1111122,2tkkkkkk $Ifgd:Lkd$$Ifl4F,$^  0$    4 laf4yt:L,2.202X2Z2222tkkkkkk $Ifgd:Lkd!$$Ifl4F,$^  0$    4 laf4yt:L22F2H2J2T2V2Z2\2p2r2t2~2222222222222222222N3R3T3p3r3ʟ|vpvpfvYjC$h`CJUjh`CJU hFtCJ h`CJhFthFtCJ h`5CJhYh`5CJh h`CJhFthFtCJaJj##h5ThJ6CJUj"h5ThJ6CJU hQ[CJjh5TCJUmHnHujh5TCJUj7"h5ThJ6CJU h5TCJ"22222:4triii $Ifgd:Lkd#$$Ifl4F,$^  0$    4 laf4yt:Lr3t3333333333338494?4@444444444444444444 5555M5O5P5^5_5`5g5ɷЪ~Ъqj+)h`CJU"j'h5Th5T>*CJUj+'h`CJUj&h`CJUh5T>*CJmHnHu"j+%h5ThJ6>*CJU h5T>*CJjh5T>*CJU hFtCJj$h`CJU h`CJjh`CJU,:4;4<45~~ $Ifgd:Lwkd&$$Ifl40$t"0$4 laf4ytk5555~~ $Ifgd:Lwkd($$Ifl40$t"0$4 laf4ytkg5h5v5w5x55555555555C6D6R6S6T6[6\6j6k6l6q6r6v66666666ɷЪylfYj#-hQ[CJU hECJj,hQ[CJUj+hQ[CJUjhQ[CJU hQ[CJhQ[5CJ\hFthFtCJaJh5T>*CJmHnHu"j*h5Th5T>*CJU h5T>*CJjh5T>*CJU hFtCJj)h`CJU h`CJjh`CJU"5555C6p6zzm <<$Ifgd:L <$Ifgd:Lwkd+$$Ifl40$t"0$4 laf4ytkp6q6r6v66 7zzm <<$Ifgd:L <$Ifgd:Lwkd,$$Ifl40$t"0$4 laf4ytk666777 777#7]7{7|7778 &(*468:<PRT^`bdfrVXtvwjj1hQ[CJUj0h5ThJ6CJUjG0h5ThJ6CJUjh5TCJUmHnHuUj/h5ThJ6CJU h5TCJjh5TCJU hECJhQ[5CJ\hFthFtCJaJj-hQ[CJUjhQ[CJU hQ[CJ) 7 777g7xx <<$Ifgd:Lwkd .$$Ifl40$t"0$4 laf4ytkg7h7m7u7y7~~~ $Ifgd:Lwkd.$$Ifl40$t"0$4 laf4ytky7z7{78:btkkkkkk $Ifgd:Lkd5/$$Ifl4F,$  0$    4 laf4ytk       FORMTEXT        FORMTEXT       VIII.Have you increased your bed capacity by 10% or more or by 10 beds, whichever is greater, within the last 2 years?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, give year of change:  FORMTEXT  Current bed space:  FORMTEXT  Prior bed space:  FORMTEXT Whoever knowingly and willfully makes or causes to be made a false statement or representation of this statement, may be prosecuted under applicable federal or state laws. In addition, knowingly and willfully failing to fully and accurately disclose the information requested may result in denial of a request to participate or where the entity already participates, a termination of its agreement or contract with the state agency or the secretary, as appropriate.Name of Authorized Representative (Printed)  FORMTEXT      Title  FORMTEXT        FORMTEXT      SignatureDate Remarks:     Texas Dept. of Family and Protective ServicesDisclosure of Ownership and Control Interest StatementForm 1513 June 2010 Page  PAGE 2 of  NUMPAGES 3 Texas Dept. of Family and Protective ServicesInstructions for Completing Disclosure of Ownership and Control Interest StatementForm 1513 June 2010 Page  PAGE 1 of  NUMPAGES 1 bdfrV0trgggTC < <<$Ifgd:L < <<$Ifgd:L <$Ifgd:Lkd31$$Ifl4F,$  0$    4 laf4ytkvx,.VXlnpԔ֔ؔ "` ϽְϞְόְzog[jhECJUaJhQ[CJaJhEhQ[CJaJhYhECJhYhQ[CJ"j4h5Th5T>*CJU"jc3h5Th5T>*CJUh5T>*CJmHnHu"j2h5ThJ6>*CJU h5T>*CJjh5T>*CJUjQ2hQ[CJU hQ[CJjhQ[CJU#~ $Ifgd:Lwkd4$$Ifl40$t"0$4 laf4ytk (dkd5$$Ifl4$$0$4 laf4ytFt <<$Ifgd:Ldkd;5$$Ifl4$$0$4 laf4ytFt0<dfhuwkd57$$Ifl40$=0$4 laf4ytFt $Ifgd:L $IfgdE  ",.0<>RTV`bhlnؙ֙ڙޙڽ|l||aYUYUYUYUh8,wjh8,wUhlhQ[CJaJj7hEh:LCJU hQ[CJjhECJUmHnHuj6hEh:LCJU hECJjhECJUhEhQ[CJaJhYhQ[CJaJ"jhECJUaJmHnHujhECJUaJ#jI6hEh:LCJUaJhECJaJ!|| $Ifgd:Lykd98$$Ifl4Z0$=0$4 laf4yt5T~ $Ifgd:Lwkd8$$Ifl40$=0$4 laf4ytFtЙҙԙ,dkd:$$Ifl4$$0$4 laf4ytFt $Ifgd:Ldkdg9$$Ifl4$$0$4 laf4ytFtԙؙ֙ܙޙL~ $$Ifa$$If  !gd4Qfkd:$$Ifl4 $$0$4 laf4ytFt LΚ֚$&(*,.›0DLXZ\^hjvογογ}p_p!jhhtCJU^JaJhhtCJ^JaJhlhtCJaJ ht5 htCJ jhht0JCJU*hs]0JCJmHnHu*jht0JCJUjhht0JCJUhht0JCJhth4QhtCJ htCJ\h4Qht5h4QhtCJ\"Κ,.Z0D~~rb$ $Ifa$gd:L $$Ifa$gd:L $Ifgd:L$a$Xkd#;$$IflFp$&T    4 la $$Ifa$ $ $Ifa$ DXZ\^}  !gd4Q$a$gd`kd;$$IflF$(4    4 laytG $$Ifa$gd:Lvxz|hlhQ[CJaJh8,whthhtCJ^JaJ!jhhtCJU^JaJhs]CJ^JaJmHnHujhtCJU^JaJ < 0 0&P1h:pQ[/ =!8"8#$%@@ < 0 0&P1h:pQ[/ =!8"8#$%@@ @ 0 0&P1h:pQ[/ =!8"8#$%@@ P 6&P1h:p/ =!8"8#$%@@ $$Ifl!vh#vD%:V l t065D%alp yt8,w$$If!vh#v#vt":V l40$55t"/ / / 4f4yt:LtDText1tDText2tDText3tDText4$$If!vh#v#v#v@ #vT#v#v:V l40$555@ 5T55/  / / 4f4yt:LtDText5$$If!vh#v#vX :V l40$55X / / 4f4yt:LtDText6tDText7tDText8tDText9vDText10$$If!vh#v#v #v#vs#v{#v:V l40$55 55s5{5/ / / 4f4yt:L$$If!vh#v$:V l40$5$/  4f4yt:L$$If!vh#v#vt":V l40$55t"/ / / 4f4yt:LtDeCheck1tDeCheck2$$If!vh#v#v#vX :V l40$555X / /  / / / 4f4yt:LtDeCheck1tDeCheck2$$If!vh#v#v#vX :V l40$555X / /  / / / 4f4yt:LtDeCheck1tDeCheck2$$If!vh#v#v#vX :V l40$555X /  / / / 4f4yt:L$$If!vh#v$:V l40$5$/  4f4yt:L$$If!vh#v#v#vX :V l40$555X /  / / 4f4yt:L$$If!vh#v#v^ #v :V l40$55^ 5 4f4yt:LvDText14vDText17vDText20$$If!vh#v#v^ #v :V l40$55^ 5 4f4yt:LvDText15vDText18vDText21$$If!vh#v#v^ #v :V l40$55^ 5 4f4yt:LvDText16vDText19vDText22$$If!vh#v#v^ #v :V l40$55^ 5 / 4f4yt:LtDeCheck1tDeCheck2tDeCheck3tDeCheck4tDeCheck5DText23P$$If!vh#v#v#vX :V l40$555X /  / / / 4f4yt:L$$If!vh#v#v#vX :V l40$555X /  / / / 4f4yt:LtDeCheck1tDeCheck2$$If!vh#v#v#vX :V l40$555X /  / / / 4f4yt:L$$If!vh#v#v^ #v :V l40$55^ 5 4f4yt:LvDText24vDText27vDText30$$If!vh#v#v^ #v :V l40$55^ 5 4f4yt:LvDText25vDText28vDText31$$If!vh#v#v^ #v :V l40$55^ 5 4f4yt:LvDText26vDText29vDText32$$If!vh#v#v^ #v :V l40$55^ 5 / 4f4yt:LtDeCheck1tDeCheck2DText33=$$If!vh#v#vt":V l40$55t"/ 4f4ytktDeCheck1tDeCheck2DText33=$$If!vh#v#vt":V l40$55t"/ 4f4ytktDeCheck1tDeCheck2DText33=$$If!vh#v#vt":V l40$55t"/ 4f4ytktDeCheck1tDeCheck2$$If!vh#v#vt":V l40$55t"/ 4f4ytktDeCheck1tDeCheck2$$If!vh#v#vt":V l40$55t"/ 4f4ytk$$If!vh#v#vt":V l40$55t"4f4ytk$$If!vh#v#v #v :V l40$55 5 4f4ytkvDText34vDText35vDText36$$If!vh#v#v #v :V l40$55 5 / 4f4ytktDeCheck1tDeCheck2DText37DText37DText37$$If!vh#v#vt":V l40$55t"/ 4f4ytk$$If!vh#v$:V l40$5$/  4f4ytFt~$$If!vh#v$:V l40$5$4f4ytFtvDText11vDText12$$If!vh#v=#v:V l40$5=54f4ytFtvDText13$$If!vh#v=#v:V l4Z0$5=54f4yt5T$$If!vh#v=#v:V l40$5=5/ 4f4ytFt$$If!vh#v$:V l40$5$/  / 4f4ytFt$$If!vh#v$:V l40$5$/ 4f4ytFt$$If!vh#v$:V l4 0$5$/ 4f4ytFt[$$If!vh#v#v&#vT:V l55&5T4a$$If!vh#v(#v4#v:V l5(5454ytGs2&6FVfv2(&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@_HmH nH sH tH L`L Normal$CJOJQJ^J_HaJmH sH tH F@F  Heading 1$xx@& 5CJ\DA`D Default Paragraph FontVi@V  Table Normal :V 44 la (k (No List 4@4 Header  !4 @4 Footer  !6B@6 Body TextxCJ.)@!. Page Numberj@3j 4Q Table Grid7:V0B'AB 7Comment ReferenceCJaJ<R< 7 Comment TextCJaJ@jQR@ 7Comment Subject5\HrH 7 Balloon TextCJOJQJ^JaJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭VvnB`2ǃ,!"E3p#9GQd; H xuv 0F[,F᚜K sO'3w #vfSVbsؠyX p5veuw 1z@ l,i!b I jZ2|9L$Z15xl.(zm${d:\@'23œln$^-@^i?D&|#td!6lġB"&63yy@t!HjpU*yeXry3~{s:FXI O5Y[Y!}S˪.7bd|n]671. tn/w/+[t6}PsںsL. J;̊iN $AI)t2 Lmx:(}\-i*xQCJuWl'QyI@ھ m2DBAR4 w¢naQ`ԲɁ W=0#xBdT/.3-F>bYL%׭˓KK 6HhfPQ=h)GBms]_Ԡ'CZѨys v@c])h7Jهic?FS.NP$ e&\Ӏ+I "'%QÕ@c![paAV.9Hd<ӮHVX*%A{Yr Aբ pxSL9":3U5U NC(p%u@;[d`4)]t#9M4W=P5*f̰lk<_X-C wT%Ժ}B% Y,] A̠&oʰŨ; \lc`|,bUvPK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!R%theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] . > |  Cfffffffffffffffffffi"#*,.0122r3g56v v"&.25:=?BEPTY\ ;!""# $$%i'())e+w+b,,b-8.f/1,11,22:455p6 7g7y7bԙD !#$%'()*+,-/01346789;<>@ACDFGHOQRSUVWXZ[JV\kw}#)1=CIU[#3;K ! !!!"!%!1!7!:!F!L!P!\!b!e!q!w!z!!!!!!!!!"%"3"C"U"a""##$$u$$$$$$$$$$$$$$$$$$$%% %%%%+%1%%%%%%%&d&t&|&&&&&,'<'D'T'h't'' (0(8(H(((((X)d)j)m)y)))))* *(*8*Z*f*{*******,,,----'---.FFFFFFFFFFG$G$G$G$G$G$FFFFFFFFFG$G$G$G$G$FG$G$FFFFFFFFFG$G$FG$G$FG$G$FG$G$G$G$FFFG$G$FFFFFFHOQVaci!!*Text1Text2Text3Text4Text5Text6Text7Text8Text9Text10Check1Check2Text14Text17Text20Text15Text18Text21Text16Text19Text22Check3Check4Check5Text23Text24Text27Text30Text25Text28Text31Text26Text29Text32Text33Text34Text35Text36Text37Text11Text12Text13Kl2J !&!;!Q!f!{!!"4"U"v$$$$$$$ % %%Y)n))Z*,--.  !"#$%&'()]~*D\ !#!8!M!c!x!!!&"D""$$$$$$%%2%&k)))|*,-.-.????]-]---.b-b-...9*urn:schemas-microsoft-com:office:smarttagsplace9*urn:schemas-microsoft-com:office:smarttagsState  !!#!%!8!:!M!P!c!e!x!z!!U""u$$$$$$$$$$$$$% %%%2%%&X)k)m))))Z*|*,,---.-P-Q-Q-S-T-T-V-W-Y-Z-\-]-----...... !!#!%!8!:!M!P!c!e!x!z!!U""u$$$$$$$$$$$$$% %%%2%%&X)k)m))))Z*|*,,---.-P-Q-----..... !!#!%!8!:!M!P!c!e!x!z!!U""u$$$$$$$$$$$$$% %%%2%%&X)k)m))))Z*|*****,,---.-P-Q-Q-T-T-g-h---------......P-Q-Q-S-T-T-V-W-Y-Z-\-]-..,+7N\V E7 9UA%4!*B3J687DG:L4QR WQ[ ]&m]s]Vd uh8,w~}wZ;~l'sPc 5TtD7?hFtY`kQ-S-@pWW !#$%e).@"L@,\@02h@UnknownG*Ax Times New Roman5Symbol3. *Cx Arial;. *Cx Helvetica5. .[`)TahomaA$BCambria Math"1h+L'+L'e+f&R&R!84:-:-2QHP ?4Q2!xx 6Disclosure of Ownership and Control Interest StatementTDPRSOverall,MaryAnn (HHSC)Oh+'0$ DP p |  8Disclosure of Ownership and Control Interest StatementTDPRSNormalOverall,MaryAnn (HHSC)2Microsoft Office Word@@aU2@,hp2O@,hp2O&՜.+,0, hp  State of TexasR:- 7Disclosure of Ownership and Control Interest Statement Title  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]_`abcdefghijklmnopqrstuvwxyz{}~Root Entry F@p2OData ^;1Table|/WordDocumentSummaryInformation(DocumentSummaryInformation8CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q