CCRC Form 4 applies to anyone in a leadership role at a Texas Continuing Care Retirement Community. Required filers include officers, directors, trustees, managing or general partners, and anyone holding a 10% or greater interest in the CCRC provider. Day-to-day management staff also fall under this requirement.
The form collects full names, current addresses, and complete educational records. Filers must list all professional associations and provide a 20-year employment history starting with the most recent position. Any bankruptcy filings, lawsuits, or judgments from the past 20 years must be disclosed. Ownership interests in other care community providers or insurance companies must also be reported.
Each filer must provide an original signature. The Texas Department of Insurance Financial Regulation Division uses this information to vet CCRC leadership. The process protects community residents and supports the ethical operation of these care services in Texas.
| Question | Answer |
|---|---|
| Form Name | Ccrc Form 4 |
| Form Length | 5 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min 15 sec |
| Issuing Agency | Texas Department of Insurance |
| Required For | CCRC Officers, Directors, Trustees |
| Other names | fin385ccrcfrm4 texas department of insurance ccrc form |