Certification of Information. The financial and operating statements provided under this Subsection need not, as an initial matter, be certified by an independent certified public accountant as having been prepared in accordance with generally accepted accounting principles, consistently applied, or, in the case of financial statements prepared on a cash or income tax basis, or of operating statements, as not materially misleading based on an audit conducted in accordance with generally accepted auditing standards. The Borrower shall, however certify that such statements are true and correct, and the Lender expressly reserves the right to require such a certification by an independent certified public accountant if a Default exists or if the Lender in the exercise of its reasonable discretion has reason to believe that any previously provided financial or operating statement is misleading in any material respect.
Certification of Information. I certify, to the best of my information and belief, that the above information that I have supplied is true and correct in all material respects.
Certification of Information. The annual financial and operating statements provided under this Subsection shall be certified by an independent certified public accountant as having been prepared in accordance with generally accepted accounting principles, consistently applied, or, in the case of financial statements prepared on a cash or income tax basis, or of operating statements, as not materially misleading based on an audit conducted in accordance with generally accepted auditing standards. The quarterly financial and operating statements provided under this Subsection need not be audited. The Borrower shall, however certify that such statements are true and correct.
Certification of Information. The Plan Sponsor certifies that the information provided on the following page, and on any exhibits hereto, is true, correct, and complete.
Certification of Information. Print the Name of the Authorized Representative – print the name of the authorized representative, Authorized Representative’s Signature – the authorized representative must sign the form. Signatures must be original, preferrably in blue ink. Stamped signatures and initials are not accepted. Date of Signature – enter the date this form was signed. MANAGED CARE ORGANIZATION (MCO) Louisiana Medicaid Registration Form Revised 10/14 Louisiana Medicaid MCO Number (if known) Registering for: New Update Reactivation Other (Please specify): Change of Ownership (CHOW) A Entity/Business Information & Location “Doing Business As” Name Area Code & Telephone Number ( ) - Street Address City State Zip Code Parish/County Parish/County Code State Status Location In-State (0) Out-of-State (1) Location Type Urban (1) Rural (2) B IRS Name & Mailing Address Business Name Registered with the IRS Number (MUST match the first line on the IRS document EXACTLY) Mailing Address Mailing City Mailing State Mailing Zip Code IRS Reporting Number Year-End Date, if applicable C General Effective Date: MCO Type Description/Code MCO (PT-05) MCO Specialty MCO- (5Q) D Contact Information The following person may be contacted for additional information regarding this registration: Contact Name: Contact Phone Number ( ) Contact Fax Number ( ) Contact Email: E Certification of Information I, the undersigned, certify the following: The information contained herein is true, correct, and complete; It is my responsibility to maintain current information on the Louisiana Medicaid files; I am an authorized party for the entity/business in Section A; and I understand that the Louisiana Medicaid files will be updated with information supplied on these forms. Print the Name of the Authorized Representative Authorized Representative’s Signature Date of Signature Original signature preferably in blue ink MANAGED CARE ORGANIZATION (MCO) GENERAL INFORMATION FOR THE DIRECT DEPOSIT (EFT) AUTHORIZATION AGREEMENT Only an authorized representative may sign this form. This authorized representative must be someone designated to enter into a legal and binding contract with Louisiana Medicaid. This person must be someone currently listed on the Disclosure of Ownership as either an owner or manager. Any other signature will be grounds for rejecting this form. Original signatures only; no stamps or copied signatures will be accepted. (Blue or colored ink preferred – not black ink). The provider name on this form must...
Certification of Information. Each of the associations named above shall certify to the District in writing, names of members and the current rate of its membership dues. Any association which shall change the rate of its membership dues shall give the District written notice prior to the effective date of such change. By mutual agreement this section may be amended.
Certification of Information. The financial and operating statements provided under this Subsection need not, as an initial matter be certified by an independent certified public accountant as having been prepared in accordance with generally accepted accounting principles, consistently applied, or, in the case of financial statements prepared on a cash or income tax basis, or of operating statements, as not materially misleading based on an audit conducted in accordance with generally accepted auditing standards. The Mortgagor shall, however certify that such statements fairly present in all material respects the financial condition of the Mortgagor, and Mortgagee expressly reserves the right to require such a certification by an independent certified public accountant if a Default exists or if Mortgagee has reason to believe that any previously provided financial or operating statement is misleading in any material respect.
Certification of Information. I certify that the information provided in this Application is complete, correct and true to the best of my knowledge.
Certification of Information. □ Yes □ No The above Purchaser and Seller have agreed to these purchase terms. Purchaser Signature: Title/Date: Seller(s) Signature(s): Owner(s): Operator(s): Title/Date:
