Laserfiche WebLink
6.1.C. - Page 66 <br />II Name Address SSN/TIN Date of Birth I <br />PART 8: CRIMINAL CONVICTIONS <br />"Agent" means any person who has been delegated the authority to obligate or act on behalf of the Entity <br />List the information below for anyone who has been convicted of a criminal offense related to that person's <br />involvement in any program under Medicare, Medicaid or the Title XX services program since the inception of the <br />program AND is listed in Parts 2 or 7 or is an Agent of the Entity. <br />II Name Address SSN/TIN Date of Birth <br />PART 9: VERIFICATION <br />I have used all resaonable diligence in preparing this statement. I have reviewed this statement and to the best of <br />my knowledge the information contained herein and in any attached pages is true and complete. I acknowledge <br />this is a public document. <br />I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct. <br />Date Signed: Signature: <br />(month/day/year) <br />Revised 3/9/2015 <br />Page 5 of 5 <br />REV: 01-17-18 RL <br />ATTY/AGR/2018.012/COUNTY OF SAN MATEO <br />(Print and sign form, submit to SHRS) <br />