Form 3722 N PDF Details

dreaded Form 3722 N. This article will provide an overview of the form, what it is used for, and helpful tips on how to complete it. dreaded Form 3722 N. This article will provide an overview of the form, what it is used for, and helpful tips on how to complete it. dreaded Form 3722 N. This article will provide an overview of the form, what it is used for, and helpful tips on how to complete it. dreaded Form 3722 N. This article will provide an overview of the form, what it is used for, and helpful tips on how to complete it. dreaded Form 3722 N. This article will provide an overview of the form, what it is used for, and helpful tips on how to complete it., The much-dreaded Form 3722 N can be a bit confusing if you don't know what you're doing. In this article we'll take a look at this little-known tax document so that you can be sure to fill it out correctly - no more headaches come tax season!

QuestionAnswer
Form NameForm 3722 N
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesillinois change of administrator form, change of administrator form illinois, application for change of nursing facility administrator form texas, nursing facility change of administrator form

Form Preview Example

Texas Dept. of Aging and Disability Services

LTC-Regulatory (E-342)

P.O. Box 149030

Austin, TX 78714-9030

(512)438-2630 FAX: (512)438-2727

APPLICATION FOR CHANGE

Nursing Facility Administrator or Administrator for Intermediate Care

Facilities for Individuals with an Intellectual Disability or Related Conditions

1.

Facility Name

 

 

 

 

 

2. Facility ID No.

 

3.

Effective Date of Change

 

 

 

 

 

 

 

 

 

 

 

4.

Physical Address (Street, City, State, ZIP)

 

 

 

 

 

 

5.

County

 

 

 

 

 

 

 

 

 

 

 

 

6.

Facility Telephone No.

 

 

7. Facility FAX No.

8. Facility Internet Address

 

 

 

 

(

)

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.

Name of New Administrator

 

 

 

 

10. Social Security No.

11. Administrator License No.

 

Expiration Date

 

(Mr., Ms., Dr.) First Name

MI

Last Name

 

(Jr., Sr.)

 

 

(attach current renewal card)

 

 

 

 

 

 

New Nursing Facility Administrator’s Permanent Address (Street, City, State, Zip)

New Nursing Facility Administrator’s Mailing Address (Street, City, State, Zip)

County

County

Submit $20 Application Fee. (Make check or money order

payable to the Texas Department of Aging and Disability Services.)..................................................................................................

Fee Enclosed

$

OWNER/APPLICANT: The facts set forth in the foregoing application are true to the best of my knowledge. I understand that submission of false information in the foregoing application will constitute grounds for denial, suspension, or revocation of my state license.

Signature–Owner/Applicant (or Authorized Representative)

 

Date

Sworn to me and subscribed before me this

day of

, 20

.

Signature–Notary Public

With a few exceptions, you have the right to request and be informed about the information that the Texas Department of Aging and Disability Services (DADS) obtains about you. You are entitled to receive and review the information upon request. You also have the right to ask DADS to correct information that is determined to be incorrect (Government Code, Sections 552.021, 552.023, 559.004). To find out about your information and your right to request correction, please contact Regulatory Services Division at (512) 438-2630.

 

 

 

 

 

 

 

CHECKLIST: Nursing Home Administrator’s Current Renewal Card (nursing facilities only)

Fee ($20.00)

Notary Signature/Seal

 

 

 

 

 

 

 

 

 

 

 

 

FOR DADS USE ONLY

Application Approval Date

Reviewer

 

 

Remittance No. and Date

Form 3722-N/November 2004

How to Edit Form 3722 N Online for Free

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Part no. 1 in submitting illinois change of administrator form

2. The third step is usually to submit all of the following blanks: OWNERAPPLICANT The facts set forth, SignatureOwnerApplicant or, Date, Sworn to me and subscribed before, day of, SignatureNotary Public, and With a few exceptions you have the.

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