Based on the first level of ownership information in Section 2, complete the next level of ownership and control interests information. Complete this section for each business unit previously specified in Section 2.a and each subsequent business unit. Disclosure of the company`s percentage of the subcontractor`s ownership – Enter the percentage of the disclosing company`s stake in the subcontractor`s business unit. The disclosing company is also required to fully disclose all persons who have a controlling interest at each level of ownership and all senior managers at each level of ownership. Form 5871 is completed and filed as a condition of approval or renewal of an application for Texas Medicaid registration or a contractual agreement between the disclosing entity (applicant/provider) and the Health and Human Services Commission (HHSC) for a service program. Full and accurate disclosure of ownership and control rights is required. Failure to submit the requested information may result in the rejection of the disclosing entity`s application for registration with Texas Medicaid, participation in HHSC programs, or, if the disclosing entity is already participating, termination of the disclosing entity`s Texas Medicaid registration and contract with HHSC. The disclosing entity is required to disclose in full all levels of ownership of 5% or more and to disclose in full all entities and natural persons at each level of ownership, from the ownership of the disclosing entity to the ownership of each subsequent owner business. The participation of 5% or more may be direct, indirect or a combination of direct and indirect ownership shares. The owner or an authorized representative of the disclosing body confirms that the information provided on the form and all appendices, if any, is true and complete.
If the legal entity is not a sole proprietorship, the authorized representative must be named on an up-to-date Form 2031, Governing Authority Resolution – Business Organization, or Form 2031-G, Governing Authority Resolution – Government Entity Filed with HHSC. Name of another disclosing entity – Enter the name of the other disclosing entity in which the above-mentioned physical or business entity has a right of ownership or control. Complete this section for all natural and legal persons listed in sections 2, 3, 4, 5, 6 or 7.a. or 7.b. If an answer to a question is Yes, provide the requested information. Legal name of the business unit – Enter the corporate name of the business entity with a 5% or greater interest in a bond secured by the assets of the disclosing company. Select Yes or No to answer both questions. If you answer both yes questions, provide the requested information. Note: A secured obligation to a business entity that is a financial institution regulated by a federal or state government does not need to be disclosed.
Directly owned shares are defined as the ownership of shares, equity or interest in the profits of the disclosing company. Indirect holdings are defined as interests in an entity that has direct or indirect interests in the disclosing entity. The amount of indirect ownership of the disclosing entity held by another entity is determined by multiplying the percentage of ownership shares at each level. Indirect ownership must be reported if it corresponds to a 5% or more interest of the disclosing company. Use a separate page for each business unit exposed at any level of the ownership structure. Example: If A holds 10% of the shares of a corporation that owns 80% of the shares of the disclosing corporation, A`s interest corresponds to an indirect interest of 8% and must be reported. Conversely, if B holds 80% of the shares of a company that holds 5% of the shares of the disclosing company, B`s interest corresponds to 4% of the indirect interest of the disclosing company and does not need to be reported. Doing Business As (d/b/a), if applicable – If applicable, enter the relevant d/b/a to this agreement. Note: A d/b/a is an assumed business name; it is not the name of the legal entity that owns the company. Do not use a d/b/a to disclose the ownership rights of a legal entity.
Contact Name – Enter the name of the person who can answer questions about the information provided in the form. Select Yes or No to answer both questions. If you answer both yes questions, provide the requested information. To determine the ownership interest on a mortgage, trust deed, note or other bond, the percentage of shares held in the bond is multiplied by the percentage of the disclosing entity`s assets used to secure the bond. .