Ch. 84

2003 LAWS OF MARYLAND

(v) If the provider is a trust, the name of the trustee, the names of
the owners of beneficial interests in the trust, the state governing the trust, and the
name of the primary individual responsible for overseeing the trust's activities;

(vi) The names and occupation of any of the officers, directors,
trustees, managing or general partners, and any other person with a 10% or greater
financial equity or beneficial interest in the provider and a description of the person's
financial interest in or occupation with the provider;

(vii) The name and address of any professional service firm,
association, trust, partnership, company, or corporation in which a person identified
in item (vi) of this paragraph has a 10% or greater financial interest and which is
anticipated to provide goods, premises, or services to the facility or provider of a value
of $10,000 or more within any fiscal year and a description of the goods, premises, or
services and their anticipated cost to the facility or provider; however, disclosure of
salary, wage, or benefit information of employees of the provider is not required; and

(viii) A statement regarding whether the provider is qualified, or
intends to qualify, as a tax exempt organization under the Internal Revenue Code;

(3)     A copy of the corporate charter, partnership agreement, articles of
association, membership agreement, trust agreement, or similar instrument or
agreement pertaining to the legal organization of the provider;

(4)     A certified financial statement of the provider for as many of the
most recent fiscal years, not exceeding 3 years, for which certified financial
statements are obtainable under generally accepted accounting principles. If the
provider's fiscal year ended more than 90 days prior to the date of filing, there shall
also be included an income statement, which need not be certified, covering the period
between the date the fiscal year ended and a date not more than 90 days prior to the
date the application is filed;

(5)     A statement as to any affiliation with a religious, charitable, or other
nonprofit organization; the extent of any affiliation, and the extent, if any, to which
the affiliate organization will be responsible for the financial and contractual
obligations of the provider;

(6)     A copy of the agreement to be entered into between the provider and
subscriber for continuing care, and any priority admission agreements between the
provider and any health care provider to provide health-related services;

(7)     A statement of the most current fee structure, including escalator or
other automatic adjustment provisions;

(8)     A statement of the role of any publicly funded benefit or insurance
program in the financing of care;

(9)     The form and substance of any advertising campaign, advertisement,
or other promotional material for the facility that has not been previously filed with
the Department; and

(10)   Other reasonable and pertinent data that the Department requires.

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