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SIGNATURE OF INDIVIDUAL COMPLETING THIS FORM DATE <br />TITLE OF INDIVIDUAL COMPLETING THIS FORM <br />NAME OF INDIVIDUAL COMPLETING THIS FORM <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. ln 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 I certifit that the <br />information provided within, is true and correct and I fully understand the consequences as explained above. <br />lX. Signature {see instructions) <br />ls a change of ownership anticipated within the next year? ..........:......... n Ves f] t'to <br />ls this facility operated by a management company or leased in whole or partly by another organization?.. fl Yes I tto <br />lf 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?........." n Yes f] ruo <br />lf yes, when? <br />Vlll. Status Ghanges (see instructions) <br />DSHS 27-094 (REV. 02/2017)Page 5