This Disclosure Statement must be delivered to all prospective residents. This Disclosure Statement must be made available to current residents upon request. This disclosure must be made within 4 months of the end of your fiscal year every year and within 90 days of any ownership or management change to the provider or home. PART I - GENERAL DISCLOSURES Provider's Legal Name: Administrative Office: Street Address: City: State: Zip: Phone: Continuing Care Facility: Street Address: City: State: Zip: Phone: CEO/Executive Director/Comparable Official: Name: Title: Phone Number: Type of Provider: A. Defined Voluntary B. For Profit Not for Profit C. Corporation Partner Individual Other: Entrance fee: Periodic fee: per: PART II - ITEMIZED DISCLOSURES Please read each item below, check the appropriate answer and provide the necessary documentation as requested by email to kid.addah@ks.gov Incomplete applications cannot be processed. Provider is individually owned. Please provide as "Exhibit A" the name(s) of any individual(s) who constitute the provider. Provider is not individually owned. Provider is a corporation, partnership or other legal entity. Please provide as "Exhibit B" thenames of the officers, directors, trustees, managing or general partners of the provider. Provider is not a corporation, partnership or other legal entity. Provider is a corporation. Please provide "Exhibit C" the name(s) of any individual(s) who own(s) 10% or more of the stock of such corporation. Provider is not a corporation or, if a corporation, no individual owns 10% or more of such corporation.. Check here if any officer, director or owner of provider has been convicted of any crime or been a party to any civil action claiming fraud, enbezzlement, fraudulent conversion or misappropriation of property, which resulted in a judgment against such person(s) Please provide "Exhibit D" the name(s) of such person(s). There are no convictions or judgments against officials, directors or owners. Check here if any person(s) has/have had any state or federal license or permit related to care and housing suspended or revoked. Please provide as "Exhibit E" the name(s) of any person(s) who has/have had any state or federal license or permit related to care and housing suspended or revoked. No suspensions or revocation. Provider/Manager has experience in the operation of homes providing continuing care. Please provide as "Exhibit F" a statement of the years of experience of the provider and/or manager in the operation of homes providing continuing care. Provider/Manager has no experience. Provider is operated on a for-profit basis or not incorporated. Please provide as "Exhibit G" the name(s) and business address(es) of any individual(s) having any ownership or beneficial interest in the provider and a description of such interest in or occupation with the provider. Provider is incorporated and not for profit. Provider is affiliated with a religious, charitable or non-profit organization. Please provide as "Exhibit H" as a statement identifying any religious, charitable or non-profit organization with which the provider is affiliated and the extent of that affiliation. Include in the exhibit any information regarding the extent to which an affiliated organization will be responsible for the financial and contractual obligations of the provider. Provider is unaffiliated. Provider (or its affiliated, if any) is/are exempt from the payment of Federal income tax under Section of the Internal Revenue Code. Provider is not exempt from Federal income tax. Provider is exempt from local property tax. Provider is not exempt from local property tax. PART III - ANNUAL AUDIT Important information PLEASE READ: The continuing care provider is required to have an annual certified audit prepared by a Certified Public Accountant and to provide a copy of the audit to the Kansas Insurance Department by email to kid.addah@ks.gov A copy of this audit must be made available to any resident or perspective resident upon request. This disclosure statement, and the information contained herein and provide hereto, is true and correct to the best of my knowledge. Signature of CEO or Executive Director: By typing your name above, you are signing this electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.
