Universal Settlement- Prior Ownership Tracker

Thank you for executing and submitting the Universal Settlement (“US”) agreement and relevant release for your facility. LeadingAge NY and Hinman Straub PC (the US trustee assigned to your facility) are seeking to verify that all prior owners that may also need to execute a US release have done so. Thank you in advance for completing this brief survey.

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* 1. Please enter the requested information:

Name of Respondent:

Title:

E-Mail Address:

Facility Name:

Operating Certificate Number:

If you are NOT the appropriate contact for Universal Settlement matters at your facility, please enter the name and e-mail address of the person who is:

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* 2. Has the not-for-profit organization or governmental entity that currently owns your facility continuously owned the facility since it was first issued an operating certificate?

Yes

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* 3. If you answered “yes” to question 2 above, please disregard the remaining questions and submit your response. If you answered “no,” please identify any prior owner(s) of the facility and the time period(s) they owned the facility in the space provided:

Prior Owner (1)

Prior Owner Time Period (1)

Prior Facility Name (1)

Prior Owner Contact Info (1)

Prior Owner (2)

Prior Owner Time Period (2)

Prior Facility Name (2)

Prior Owner Contact Info (2)

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* 4. If you completed question 3, please indicate to the best of your belief whether the facility purchase and transfer agreement your organization executed with the prior owner(s) conferred any rights on the prior owner(s) to the value of any unprocessed rate appeals or unresolved litigation on Medicaid rate issues:

Yes, the prior owner may be entitled to funds for these items

No, the prior owner does not have rights to funds for these items

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* 5. If you answered no to question 2, have you contacted the prior owner(s) to apprise them of the US and the potential need to submit an executed US agreement and release?

Yes

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* 1. Please enter the requested information:

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* 2. Has the not-for-profit organization or governmental entity that currently owns your facility continuously owned the facility since it was first issued an operating certificate?

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* 3. If you answered “yes” to question 2 above, please disregard the remaining questions and submit your response. If you answered “no,” please identify any prior owner(s) of the facility and the time period(s) they owned the facility in the space provided:

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* 5. If you answered no to question 2, have you contacted the prior owner(s) to apprise them of the US and the potential need to submit an executed US agreement and release?

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* 6. Please enter any additional information/comments: