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STREET NAME AND NUMBER, SUITE, ROOM, ETC.CITY STATE ZIP CODE <br />SOCIAL SECURITY NUMBER <br />FIRST NAME <br />List each managing employee and other controlling interests (e.9. members of a board of directors or an officer) of the <br />provider listed in Section l. Attach additional pages as necessary. <br />FIRST NAME <br />FIRST NAME <br />lf the individualbeing disclosed is related (spouse, parent, child, sibling)to anotherowner, managing employee, or <br />controlling interest of the provider listed in Section l, list related individual(s): <br />STREET NAME AND NUMBER, SUITE, ROOM, ETC CITY STATE ZIP CODE <br />DATE OF BIRTH <br />FIRST NAME <br />List each managing employee and other controlling interests (e.9. members of a board of directors or an officer) of the <br />provider listed in Section L Attach additional pages as necessary. <br />lll. Managing Employees and other Controlling lnterests (see instruetions) <br />FIRST NAME <br />FIRST NAME <br />lf 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 l, list related individual(s): <br />STREET NAME AND NUMBER, SUITE, ROOM, ETC.CITY STATE ZIP CODE <br />SOCIAL SECURITY NUMBER <br />FIRST NAME <br />List each individualwho 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 l. Attach additional pages as necessary. <br />FIRST NAME <br />FIRST NAME <br />lf the individual being disclosed is related (spouse, parent, child, sibling) to another owner, managing employee, or <br />individualwith controlling interest of the provider listed in Section l, list related individual(s): <br />STREET NAME AND NUMBER, SUITE, ROOM, ETC.CITY STATE ZIP CODE <br />SOCIAL SECURITY NUMBER <br />FIRST NAME <br />List each individualwho has direct or indirect ownership, separately or in combination, amounting to an ownership <br />interest ol So/o or more of the provider listed in Section l. Attach additional pages as necessary. <br />ll. lndividuals with Ownership lnterest (continued) <br />START DATE <br />LAST NAME <br />LAST NAME <br />SOCIAL SECURITY NUMBER <br />LAST NAME <br />LAST NAME <br />START DATE <br />LAST NAME <br />LAST NAME <br />LAST NAME <br />START DATE <br />LAST NAME <br />LAST NAME <br />LAST NAME <br />DATE OF BIRTH <br />RELATIONSHIP <br />RELATIONSHIP <br />START DATE <br />RELATIONSHIP <br />RELATIONSHIP <br />OWNERSHIP PERCENTAGE <br />DATE OF BIRTH <br />RELATIONSHIP <br />RELATIONSHIP <br />OWNERSHIP PERCENTAGE <br />DATE OF BIRTH <br />DSHS 27-094 (REV. 02/2017)Page 2