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Click ‘Get Form’ to open the ownership disclosure form omma in the editor.
Begin by filling out the Identifying Information section. Enter your legal name as per IRS records, DBA (Doing Business As), address, NPI, and contact details accurately.
In the Structure section, select the appropriate entity type that describes your business structure from the provided options.
For Ownership & Control Interests, list each person with an ownership interest. Provide their full legal name, address, percentage of ownership interest, SSN or FEIN, driver's license number, and relationship to you.
Complete the Significant Business Transactions section by reporting any transactions exceeding $25,000 with subcontractors over the past year. If none exist, indicate 'N/A'.
Answer questions regarding Excluded Individuals or Entities honestly. If applicable, provide names and reasons for any exclusions.
Finally, certify that all information is accurate by signing and dating the certification section at the end of the form.

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