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III. Managing Employees and Other Controlling Interests (continued) If the individual being disclosed is related (spouse, parent, child, sibling) to another owner, managing employee, or controlling interest of the provider listed in Section I, list related individual(s): FIRST NAME LAST NAME RELATIONSHIP FIRST NAME LAST NAME RELATIONSHIP List each managing employee and other controlling interests (e.g. members of a board of directors or officers)of the provider listed in Section I. Attach additional pages as necessary. FIRST NAME LAST NAME SOCIAL SECURITY NUMBER START DATE DATE OF BIRTH STREET NAME AND NUMBER, SUITE, ROOM, ETC. CITY STATE ZIP CODE If the individual being disclosed is related (spouse, parent, child, sibling) to another owner, managing employee, or controlling interest of the provider listed in Section I, list related individual(s): FIRST NAME LAST NAME RELATIONSHIP FIRST NAME LAST NAME RELATIONSHIP IV. Organizations with Ownership or Management Interest see instructions List each office, organization, corporation or entity that has a management interest or direct/ indirect ownership separately or in combination, amounting to an ownership interest of 5% or more in the provider listed in Section I. Attach additional pages as necessary. ORGANIZATION NAME (LEGAL NAME) FEDERAL TAX ID - FEIN CHECK ONE ❑ Ownership Interest ❑ Management Interest DOING BUSINESS AS (DBA) START DATE OWNERSHIP PERCENTAGE PRIMARY BUSINESS STREET ADDRESS CITY STATE ZIP CODE Mailing Address (PO Box) for the disclosed organization, if different from Primary Business Address MAILING ADDRESS CITY STATE ZIP CODE Business Locations for the disclosed organization, if different from the Primary Business Address STREET NAME AND NUMBER, SUITE, ROOM„ ETC. CITY STATE ZIP CODE STREET NAME AND NUMBER, SUITE, ROOM, ETC. CITY STATE ZIP CODE List each office, organization, corporation or entity that has a management interest or direct/indirect ownership separately or in combination, amounting to an ownership interest of 5% or more in the provider listed in Section I. Attach additional pages as necessary. _ ORGANIZATION NAME (LEGAL NAME) FEDERAL TAX ID - FEIN CHECK ONE ❑ Ownership Interest Marla ement Interest DOING BUSINESS AS (DBA) START DATE OWNERSHIP PERCENTAGE PRIMARY BUSINESS STREET ADDRESS CITY STATE ZIP CODE Mailing Address (PO Box) for the disclosed organization, if different from Primary Business Address MAILING ADDRESS CITY STATE ZIP CODE DSHS 27-094 (REV. 02/2017) Page 3