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IV. Organizations with Ownership or Management Interest (continued) 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 ANO NUMBER, SUITE, ROOM, ETC. CITY STATE ZIP CODE V. Subcontractor Information (see instructions) List each person with an ownership or controlling interest in any subcontractor in which the provider listed in Section I has direct or indirect ownership of 5% or more. Attach additional pages as necessary - NAME AND TITLE SSN /TIN PERCENTAGE ADDRESS CITY STATE ZIP CODE TITLE ADDRESS CITY SSN / TIN STATE ZIP CODE Does any owner of the provider listed in Section I also have an ownership or controlling interest of 5% or more in any other entity? Attach additional pages as necessary. NAME AND TITLE SSN / TIN ,1 PERCENTAGE 1-1810104X� GTY STATE ZIP CODE VI. Criminal Offenses see instructions List each individual who has ownership, controlling interest, is an agent, managing employee, officer, or member of the board of directors of the provider listed in Section I and has been convicted of a criminal offense related to that person's involvement in any program under Medicare, Medicaid, or Title XVIII, XIX, or XX, since the inception of those programs. Attach additional pages as necessary. NAME AND TITLE SSN / TIN 1 PERCENTAGE T—D—DRESS CITY STATE ZIP CODE TITLE ADDRESS CITY SSN/TIN PERCENTAGE STATE ZIP CODE VII. Suspension or Debarment (see instructions] Federal statutes and regulations clearly prohibit states from paying for items or services furnished, ordered or prescribed by excluded parties. States are required to search the exclusions databases by the name of a provider entity seeking to participate in the program and also by the name of any owner, managing employee, or controlling interests including officers and members of a board of directors. Have you, any of your managing employees, or any individual who has an ownership or controlling interest of the provider listed in Section I ever been placed on the federal Office of the Inspector General, Health and Human Services (OIG/HHS) exclusions list or on the System for Award Management (SAM), or otherwise been suspended or debarred from participation in Medicare. Medicaid, or Title XVIII, XIX, or XX services programs. If yes, list each person below. Attach additional pages as necessary. The lists of excluded individuals can be found at: http://exclusions.oi� hl hs.clov/ and https://www.sam.gov. NAME AND TITLE SSN / TIN DATE OF BIRTH ADDRESS CITY STATE ZIP CODE NAME AND TITLE ADDRESS DSHS 27-094 (REV. 02/2017) SSN 1 TIN I DATE OF BIRTH STATE ZIP CODE Page 4