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Martin O'Malley, Governor
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Ch.3
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(II) FOR A PARTNERSHIP, THE NAMES OF THE GENERAL PARTNERS,
THE STATE GOVERNING ITS FORMATION, AND THE NAME OF THE PRIMARY
INDIVIDUAL RESPONSIBLE FOR MANAGING IT;
(III) FOR AN UNINCORPORATED ASSOCIATION, THE NAMES OF THE
MEMBERS, THE STATE GOVERNING ITS ACTIVITIES, AND THE NAME OF THE PRIMARY
INDIVIDUAL RESPONSIBLE FOR MANAGING IT;
(IV) FOR A PARTNERSHIP THAT HAS A CORPORATION OR LIMITED
LIABILITY COMPANY AS ONE OR MORE OF ITS GENERAL PARTNERS, THE NAME OF
EACH CORPORATION OR LIMITED LIABILITY COMPANY, THE STATE IN WHICH IT IS
INCORPORATED OR FORMED, AND THE NAME OF THE CHIEF EXECUTIVE OFFICER;
(V) FOR A TRUST, THE NAME OF THE TRUSTEE, THE NAMES OF THE
OWNERS OF BENEFICIAL INTERESTS IN THE TRUST, THE STATE GOVERNING IT, AND
THE NAME OF THE PRIMARY INDIVIDUAL RESPONSIBLE FOR OVERSEEING ITS
ACTIVITIES;
(VI) THE NAME AND OCCUPATION OF EACH OFFICER DIRECTOR
TRUSTEE, MANAGING OR GENERAL PARTNER, AND EACH 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 ENTITY IN WHICH A PERSON
IDENTIFIED IN ITEM (VI) OF THIS PARAGRAPH HAS A 10% OR GREATER FINANCIAL
INTEREST AND THAT IS ANTICIPATED TO PROVIDE GOODS, PREMISES, OR SERVICES
WITH A VALUE OF $10,000 OR MORE TO THE FACILITY OR PROVIDER IN A FISCAL YEAR
AND A DESCRIPTION OF THE GOODS, PREMISES, OR SERVICES AND THEIR
ANTICIPATED COST TO THE FACILITY OR PROVIDER WHICH NEED NOT INCLUDE
SALARY, WAGE, OR BENEFIT INFORMATION OF EMPLOYEES OF THE PROVIDER; AND
(VIII) A STATEMENT 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 GOVERNING THE LEGAL ORGANIZATION OF
THE PROVIDER;
(4) (I) 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; AND
(II) IF THE PROVIDER'S FISCAL YEAR ENDED MORE THAN 90 DAYS
BEFORE THE DATE THE APPLICATION IS FILED, AN INCOME STATEMENT, WHICH
NEED NOT BE CERTIFIED, COVERING THE PERIOD BETWEEN THE END OF THE
FISCAL YEAR AND A DATE NOT MORE THAN 90 DAYS BEFORE THE DATE THE
APPLICATION IS FILED;
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- 435 -
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