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VIII. Status Changes Isee instructionS <br />Is a change of ownership anticipated within the next year?........................................................................... ❑ Yes [-]No <br />Is this facility operated by a management company or leased in whole or partly by another organization?.. ❑ Yes ❑ No <br />If yes, list date of change in operations: <br />Has there been a past bankruptcy or do you anticipate filing for bankruptcy within the next year? ............... ❑ Yes ❑ No <br />If yes, when? — — <br />IX. Signature (see instructions] <br />Anyone who knowingly and willfully makes or causes to be made a false statement or representation of this statement <br />may be prosecuted under applicable federal or state laws. In addition, knowingly and willfully failing to fully and <br />accurately disclose the information requested may result in denial of a request to participate or where the entity already <br />participates, a termination of its agreement or contract with the appropriate state agency. By signature 1 certify that the <br />information provided within, is true and correct and I fully understand the consequences as explained above. <br />F NAME of INDIVIDUAL COMPLETING THIS FORM <br />TITLE OF INDMDUAL COMPLETING THIS FORM <br />SIGNATURE OF INDIVIDUAL COMPLETING THIS FUKM <br />DATE <br />DSHS 27-094 (REV. 02/2017) Page 5 <br />