Fill and Sign the Indiana Standard Residential Lease Agreement Template Eforms

State of Connecticut Office of Health Care Access CON Determination Form Relocation of a Health Care Facility All persons who are requesting a determination from OHCA as to whether a CON is required for their proposed relocation of a health care facility must complete this form. The completed form should be submitted to the Director of the Office of Health Care Access, 410 Capitol Avenue, MS#13HCA, P.O. Box 340308, Hartford, Connecticut 06134-0308. SECTION I. PETITIONER INFORMATION If this proposal has more than two Petitioners, please attach a separate sheet, supplying the same information for each Petitioner in the format presented in the following table. Petitioner Full Legal Name Doing Business As Name of Parent Corporation Petitioner’s Mailing Address, if Post Office (PO) Box, include a street mailing address for Certified Mail What is the Petitioner’s Status: P for profit and NP for Nonprofit Contact Person at Facility, including Title/Position: This Individual at the facility will be the Petitioner’s Designee to receive all correspondence in this matter. Petitioner Page 2 of 3 8/17/11 Contact Person’s Mailing Address, if PO Box, include a street mailing address for Certified Mail Contact Person’s Telephone Number Contact Person’s Fax Number Contact Person’s e-mail Address SECTION II. INFORMATION ON PROPOSED RELOCATION Please provide a description of the proposed relocation, highlighting each of its important aspects, on at least one, but not more than two separate 8.5” X 11” sheets of paper. At a minimum each of the following elements need to be addressed, if applicable. Name of the Health Care Facility: Current Location: Proposed Location: Current Population Served: Proposed Population Served: Current Payor Mix: Proposed Payor Mix: Any other information that the Petitioner deems relevant: Form 2020 Revised 08/11 Page 3 of 3 8/17/11 SECTION V. AFFIDAVIT (Each Petitioner must submit a completed Affidavit.) Petitioner: _____________________________________________________________ Project Title: ___________________________________________________________ I, _____________________________________, ______________________________ (Name) (Position – CEO or CFO) of ____________________________________being duly sworn, depose and state that the (Organization Name) information provided in this CON Determination form is true and accurate to the best of my knowledge. __________________________________________ Signature _________________________ Date Subscribed and sworn to before me on______________________________________ _____________________________________________________________________ Notary Public/Commissioner of Superior Court My commission expires: __________________________________________________ Form 2020 Revised 08/11