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II. Individuals with Ownership Interest (continued) <br />List each individual who has direct or indirect ownership, separately or in combination, amounting to an ownership <br />interest of 5% or more of the provider listed in Section I. Attach additional pages as necessary. <br />FIRST NAME LAST NAME DATE OF BIRTH <br />SOCIAL SECURITY NUMBER START DATE OWNERSHIP PERCENTAGE <br />STREET NAME AND NUMBER, SUITE, ROOM, ETC. CITY STATE ZIP CODE <br />If the individual being disclosed is related (spouse, parent, child, sibling) to another owner, managing employee, or <br />individual with controlling interest of the provider listed in Section I, list related individual(s): <br />FIRST NAME LAST NAME RELATIONSHIP <br />FIRST NAME LAST NAME RELATIONSHIP <br />List each individual who has direct or indirect ownership, separately or in combination, amounting to an ownership <br />interest of 5% or more of the provider listed in Section I. Attach additional pages as necessary. <br />FIRST NAME LAST NAME DATE OF BIRTH <br />SOCIAL. SECURITY NUMBER <br />START DATE <br />OWNERSHIP PERCENTAGE <br />STREET NAME AND NUMBER, SUITE, ROOM, ETC. CITY STATE ZIP CODE <br />If the individual being disclosed is related (spouse, parent, child, sibling) to another owner, managing employee, or <br />individual with controlling interest of the provider listed in Section I, list related individual(s): <br />FIRST NAME LAST NAME RELATIONSHIP <br />FIRST NAME LAST NAME RELATIONSHIP <br />III. Managing Employees and other Controlling Interests (see instructions) 1 <br />List each managing employee and other controlling interests (e.g. members of a board of directors or an officer) of the <br />provider listed in Section I. Attach additional pages as necessary. <br />FIRST NAME LAST NAME <br />DATE OF BIRTH SOCIAL SECURITY NUMBER START DATE <br />STREET NAME AND NUMBER, SUITE, ROOM, ETC. CITY STATE ZIP CODE <br />If the individual being disclosed is related (spouse, parent, child, sibling) to another owner, managing employee, or <br />controlling interest of the provider listed in Section I, list related individual(s): <br />FIRST NAME <br />LAST NAME <br />RELATIONSHIP <br />FIRST NAME <br />LAST NAME <br />RELATIONSHIP <br />List each managing employee and other controlling interests (e.g. members of a board of directors or an officer) of the <br />provider listed in Section I. Attach additional pages as necessary. <br />FIRST NAME LAST NAME <br />SOCIAL SECURITY NUMBER START DATE DATE OF BIRTH <br />i <br />STREET NAME AND NUMBER, SUITE, ROOM, ETC. CITY STATE ZIP CODE <br />DSHS 27-094 (REV. 02/2017) Page 2 <br />