Form Dhcs 5083 - California Administrative Organization Corporations - Health And Human Services Agency
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1State of California — Health and Human Services Agency
Department of Health Care Services
Licensing and Certification Branch, MS 2600
PO Box 997413
Sacramento, CA 95899-7413
A- 3A – ADMINISTRATIVE ORGANIZATION – CORPORATIONS
INSTRUCTIONS: Attach a copy of approved articles of incorporation papers from the Secretary of State. This form
must be updated and submitted to the Department of Health Care Services each time there is a change in officers
or change in the corporation.
CORPORATION
Name (as listed with the Secretary of State)
Chief Executive Officer
Incorporation Date
Place of Incorporation
Principal office of business:
Address:
City:
Zip Code:
Phone:
Contact Person:
Title:
Telephone:
Names and addresses of all persons who own ten percent (10%) or more of stock in corporation.
Governing Board of Directors:
a. Number of Board Members:
b. Term of Office:
c. Frequency of Meetings:
d. Method of Selection:
Board Officers and Members
USE A SEPARATE SHEET FOR ADDITIONAL NAMES
Office
Name
Business Address & City & Zip
Telephone
Term Expire
Code
Number
Date
President
Vice-
President
Secretary
Treasurer
Other
Other
Other
DHCS 5083 (07/13)
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