State Form 49883 - Renewal Application For License Approval To Operate A Hospice Page 2

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SECTON IV - OWNERSHIP INFORMATION

A. Applicant Entity (Owner/Operator)

If a change of ownership has occurred, you must submit a change of ownership application to this division.

Name of Applicant Entity-Licensee (operator(s) of the facility)

B. Ownership Information (officers/directors/managing agents/managing employees of the home health agency)

Has the facility changed individuals with direct or indirect ownership?

(If yes, complete below)

Yes

List names and addresses of individuals or organizations having direct or indirect ownership or controlling interest of five percent (5%) or more in the

applicant entity. Indirect ownership interest is an entity that has an ownership interest in the applicant entity. Ownership in any entity higher in a

pyramid than the applicant constitutes indirect ownership. (use additional sheet if necessary)

Name

Business Address (street address/city/state/zip)

EIN Number

C. Type of Entity

For Profit

NonProfit

Government

Individual

Church Related

State

* Partnership

Individual

County

** Corporation

* Partnership

City

*** Limited Liability Company

** Corporation

City/County

Sole Proprietorship

*** Limited Liability Company

Hospital District

Other (specify)______________________________

Other (specify)______________________

Federal

_____________________________________________

_____________________________________

Other (specify)_______________

D. Directors/Officers/ Partners/Managing Agents/Managing Employees (Director owners)

Has the facility changed officers, partners and/or directors?

(If yes, complete below)

Yes

List all individuals (persons) associated with the applicant entity and indicate the individual’s title (i.e. officer, director, member, partner, president, vice

president, secretary, etc). If the applicant is a partnership, list the name and title of each partner or the name and title of all individuals associated with

each entity that forms the partnership. If the applicant is a Limited Liability Company, list the name and title for all individuals associated with each

member entity that forms the Limited Liability Company.

(use additional sheet if necessary)

Business Address

Officer/Partner/Director Name

Title

Telephone Number

(street address/city/state/zip)

SECTON V - CERTIFICATION OF APPLICATION

I hereby certify that operational policies of this facility will not provide for discrimination based upon race, color, creed, or national origin.

I swear or affirm that all statements made in this application, and any attachments thereto, are correct to the best of my knowledge and that I will comply

with all laws, rules and regulations governing and licensing of hospice programs in Indiana.

Applicant’s signature as indicated in section II of this application, or signature of applicant’s agent, should appear below.

If signed by any individual (e.g., the administrator) other that indicated in section II of this application, an affidavit must be submitted with the application

to affirm that said person has been given the power to bind the applicant/licensee.

Name of Authorized Representative (Typed/Printed)

Title

Signature of Authorized Representative

Date (month/day/year)

RETURN APPLICATION AND A NON-REFUNDABLE LICENSE FEE OF $100.00 TO:

INDIANA STATE DEPARTMENT OF HEALTH

ATTENTION: CASHIER, 2

FLOOR

2 NORTH MERDIAN STREET

INDIANAPOLIS, INDIANA 46204-3003