Arizona disclosure ownership form: Fill out & sign online

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Click ‘Get Form’ to open it in the editor.
Begin with Item I, Identifying Information. Fill in your name, DBA name, and Federal Tax Identification Number (TIN) or Social Security Number (SSN). Select the entity type that best describes your organization by checking one box.
Proceed to Item II, Ownership and Control Interest Information. List all individuals and entities with a 5% or more ownership interest. Include their names, titles, addresses, SSNs/TINs, dates of birth, and ownership percentages.
In Item III, Criminal Offenses, provide details for any individuals with ownership interests who have been convicted of crimes related to Medicare or Medicaid programs. Ensure you include their names, titles, addresses, and SSNs.
Complete Item IV by listing the Board of Directors' names, titles, and addresses. Finally, affirm the accuracy of your information by signing and dating the form.

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