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Martin O'Malley, Governor
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Ch.3
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(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; AND
(VI) A STATEMENT WHETHER THE PROVIDER IS QUALIFIED, OR
INTENDS TO QUALIFY, AS A TAX-EXEMPT ORGANIZATION UNDER THE INTERNAL
REVENUE CODE;
(4) THE NAME AND OCCUPATION OF EACH OFFICER DIRECTOR
TRUSTEE, MANAGING OR GENERAL PARTNER, AND EACH PERSON WITH A 10% OR
GREATER EQUITY OR BENEFICIAL INTEREST IN THE PROVIDER AND A DESCRIPTION
OF THE PERSON'S FINANCIAL INTEREST IN OR OCCUPATION WITH THE PROVIDER;
(5) THE NAME AND ADDRESS OF ANY ENTITY IN WHICH A PERSON
IDENTIFIED IN ITEM (4) OF THIS SUBSECTION 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;
(6) A DESCRIPTION OF ANY MATTER IN WHICH AN INDIVIDUAL
IDENTIFIED IN ITEM (4) OF THIS SUBSECTION:
(I) HAS BEEN CONVICTED OF A FELONY OR PLEADED NOLO
CONTENDERE TO A FELONY CHARGE, IF THE FELONY INVOLVED FRAUD,
EMBEZZLEMENT, FRAUDULENT CONVERSION, OR MISAPPROPRIATION OF PROPERTY;
(II) HAS BEEN HELD LIABLE OR ENJOINED IN A CIVIL ACTION BY
FINAL JUDGMENT, IF THE CIVIL ACTION INVOLVED FRAUD, EMBEZZLEMENT,
FRAUDULENT CONVERSION, OR MISAPPROPRIATION AS A FIDUCIARY;
(III) HAS BEEN SUBJECT TO AN EFFECTIVE INJUNCTIVE OR
RESTRICTIVE ORDER OF A COURT OF RECORD IN AN ACTION THAT AROSE OUT OF OR
RELATED TO BUSINESS ACTIVITY OR HEALTH CARE, INCLUDING AN ACTION THAT
AFFECTED A LICENSE TO OPERATE A FACILITY OR SERVICE FOR SENIOR IMPAIRED,
OR DEPENDENT PERSONS; OR
(IV) IN THE PAST 10 YEARS, HAD A STATE OR FEDERAL LICENSE OR
PERMIT SUSPENDED OR REVOKED BECAUSE A GOVERNMENTAL UNIT BROUGHT AN
ACTION THAT AROSE OUT OF OR RELATED TO BUSINESS ACTIVITY OR HEALTH CARE,
INCLUDING AN ACTION THAT AFFECTED A LICENSE TO OPERATE A FACILITY OR
SERVICE FOR SENIOR IMPAIRED, OR DEPENDENT PERSONS;
(7) A DESCRIPTION OF THE PROVIDER'S FORM OF GOVERNANCE AND
THE COMPOSITION OF ITS GOVERNING BODY, AND A STATEMENT THAT THE
PROVIDER WILL SATISFY THE REQUIREMENTS OF §§ 10-426 AND 10-427 OF THIS
SUBTITLE;
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- 451 -
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