Continuing Care Provider Application For

1 CONTINUING CARE PROVIDER APPLICATION FOR CERTIFICATE OF REGISTRATION The undersigned hereby applies to the Secretary of the Kansas Department for Aging and Disability Services for a CERTIFICATE OF REGISTRATION pursuant to K.S.A. 40-2231 through 40-2238. [...] 40-2237, if there is a change of ownership, or management of the provider or home, the new owners must file all required documents within 90 days of change. [...] Email application and the following supporting documentation to KDADS. [...] The CPA audit must be filed with the Secretary within 4 months of completion of such provider’s fiscal year. [...] • Annual Disclosure Statement Certification • Copies of any continuing care contract form entered into, to include contracts between the provider and any resident, which shall contain or have attached thereto: o A description of all fees and or charges required of residents, a description of all services to be provided or committed to providing in the future in compliance with the definitions [...] • Provide most recent floor plans for every place or facility that encompasses the continuum of aging care needs within this CCRC. [...] • Submit appropriate application fee by check or money order made payable to “Kansas Department for Aging and Disability Services” or “KDADS” and mail to: KDADS Attn: Patty Purdon 503 S Kansas Ave Topeka, KS 66603 [Signature Page Follows]3 Undersigned hereby submits this application and supporting documents for a CERTIFICATE OF REGISTRATION pursuant to K.S.A. 40-2231 through K. [...] 40-2238, authorizing the above-named continuing care provider to operate or continue to operate in the State of Kansas until such certificate is suspended, revoked, or terminated by the Secretary for Aging and Disability Services. Undersigned hereby certifies the continuing care provider making this application is in compliance with the requirements of K.S.A. 40-2231 through K [...] I have read the contents of this application. [...] My signature legally and financially binds the above- named continuing care provider to the laws, regulations, and program instructions of the State of Kansas. By my signature, I certify that I am a duly appointed representative of the above-named provider, that I am authorized to execute and file this application, that the information contained herein and attached hereto is true, correct, and