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i 9elYe°ce No of Doc~1 ».W <br />CONTINUATION SHEET ° <br />HDrw OF OIIYo. n CanNmIO <br />1 ) Off.,. it .n g.ncy or Lnetr,oeoulaq of . td.rLL, Star-, or loin im.roae°c: <br />. Otber, S[.[e bed.. <br />Id) Corporate State.. <br />1 I Corp°,.tics prmidLei ..dlul .d health care se"icu or aeisl d u the blllLag and rollectLng o1 pgauu for each <br />unteeat <br />(� other corporate eatLgl Non-profit Corporation <br />1 1 Not . carpomts encltyl <br />( 1 Sole proptcetnrthLp <br />1 1 hruerrhLp <br />I ) deacrlhed is I6 CR 501lr1171 the[ le asap[ !rw eaeacim coder 26 CR S011.l. <br />go.piul or "tedd tar. facility <br />(a) Ceam Par.or. <br />( 1 Off.ror Le Or canad cs tmcrolld by . coe.m pare-[ a. d.finad to p ..Vc.ph (a) of chi. prmidm. <br />( ) S.ea end TIP of coaaoa parent. <br />Naea I <br />Till I <br />(V 70LI ) <br />1-2 CQTLrICLTIOP giulD1PG DDLARKW. SUSPO617N, PIDPOSED DMLIMT, LID OTM [LSPONSIE=Tf UTMSit1 <br />72.I09-7 <br />(.)(1) The Offecur e.etifiae. to the beat of it. laoal.dS. ad belief, that- <br />(L) no (1!leses adi. my of it, PrLnelp.10- <br />IS) Lee I ) <br />ere ant (g) <br />pr•�uy debarred, ypmdd, Prapoed ford.basaenc, cs declared Lneliiule ten the .ward of cmcenu by any Padesal agency, <br />(p gav ( ) <br />bav not W. <br />d'.,' . 7-yaec period prac.ding thi.aff.c, Men emaleud of or bad• clan )dgrot r.d.sd apivc tba fort eoaia.lm Of <br />trued cs • crt tanl ofla ae a tuou.cPtLM .r+Ltd L obuWnS, .,urtaapcingutod <br />ebta[n, or parforng a pmbUt (federal, aua, or local) <br />tOrwbemtru:cl vLaLclm of dcs -tau accitr[ eraue ,.Lung m tee .abdm asiof offnal w eam laalof <br />trued or <br />wba slaaenc, tbafc, forgery, bribery, t.l.ificadm or descraecim of nevrde, stlW laL..utae�u, cs nnelaly aulr <br />pcvparcyl " <br />IC) Lea ( ) <br />at. ont tr ) <br />pr..ucly l�o� for. or ocbralaa cr[alully of civilly charSed 1R • imetea,nul uslcy with, cmlaeim of my of tb. <br />ot[eaea. ewrrat.d Ln aabdbL•m (U(IIIU(S) of thle prmLLLm. <br />(Li) Th. Off.rm bee ( ) <br />Us act (x). <br />.Lthio a 7-year Period pucad[y thia offer, bad one or ante cmmcu caraia.cd for default by aq Iad.sal .gaol• <br />(21 'Principals,• for tie. porpoSea of ul. &rclfLce1Lm. aeaoe offlurel dLrucmal oaearal parueral and, Pereoae <br />