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MAILING ADDRESS CITY STATE ZIP CODE <br />Mailing Address (PO Box) for the disclosed organization, if different from Primary Business Address <br />PRIMARY BUSINESS STREET ADDRESS CITY STATE ZIP CODE <br />DOrNG BUSTNESS AS (DBA) <br />oRGANTZATTON NAME (LEGAL NAME) <br />List each office, organization, corporation or entity that has a management interest or direct/indirect ownership <br />'separately or in combination, amounting to an ownership interest of 5% or more in the provider listed in Section L Attach <br />additional pages as necessary. <br />STREET NAME AND NUMBER, SUITE, ROOM, ETC CITY STATE ZIP CODE <br />STREET NAME AND NUMBER, SUITE, ROOM, ETC CITY STATE ZIP CODE <br />Business Locations for the disclosed organization, if different from the Primary Business Address <br />MAILING ADDRESS CITY STATE ZIP CODE <br />Mailing Address (PO Box) for the disclosed organization, if different from Primary Business Address <br />PRIMARY BUSINESS STREET ADDRESS CITY STATE ZIP CODE <br />DOING BUSINESS AS (DBA) <br />ORGANIZATION NAME (LEGAL NAME) <br />List each office, organization, corporation or entity that has a management interest or direct/ indirect ownership <br />separately or in combination, amounting to an ownership interest of 5o/o or more in the provider listed in Section l. Attach <br />additional pages as necessary. <br />lV. Organizations with Ownership or Management lnterest (see instructions) <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 />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 SECURIry NUMBER <br />FIRST NAME <br />List each managing employee and other controlling interests (e.9. members of a board of directors or officers)of the <br />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 />controlling interest of the provider listed in Section l, list related individual(s): <br />lll. Managing Employees and Other Controlling lnterests (continued) <br />LAST NAME <br />LAST NAME <br />START DATE <br />LAST NAME <br />LAST NAME <br />START DATE <br />FEDERAL TAX ID - FEIN <br />START DATE <br />FEDEML TAX ID . FEIN <br />LAST NAME <br />RELATIONSHIP <br />RELATIONSHIP <br />DATE OF BIRTH <br />RELATIONSHIP <br />RELATIONSHIP <br />OWNERSHIP PERCENTAGE <br />CHECK ONE <br />I Ownership lnterest <br />[-l Manaqement lnterest <br />OWNERSHIP PERCENTAGE <br />CHECK ONE <br />n Ownership lnterest <br />l-l Manaqement lnterest <br />DSHS 27-094 (REV. 02/2017)Page 3