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6.1.C. - Page 67 <br />San Mateo County <br />o. o <br />Behavioral Health & Recovery Services <br />Cq<lFORN`4 <br />FORM 700 ATTESTATION <br />This attestation must be signed by an individual with the authority to sign on behalf of the organization they represent to attest <br />to the accuracy and completeness of the information provided. <br />Entity <br />Name: Date: <br />DBA Name <br />if any: <br />Address: <br />Street Address Unit # <br />City State ZIP Code <br />Phone: Email <br />Federal Tax ID: <br />Check the type that best describes the structure of Entity. Check only one box. <br />For -Profit Corporation ❑ Non -Profit Corporation ❑ Partnership ❑ Government Owned ❑ LLC ❑ <br />Ownership or Control Interest <br />YES NO <br />Review the attached Form 700. Has ownership or control interest for the entity changed? ❑ ❑ <br />If YES, stop here - a new Form 700 must be completed. <br />1 hereby certify under penalty of perjury that, to the best of my knowledge, my answers are true and complete. I <br />further acknowledge that this is a public document. <br />Signature: <br />Print Name: <br />Print Title: <br />1 <br />REV: 01-17-18 RL <br />ATTY/AGR/2018.012/COUNTY OF SAN MATEO <br />Date: <br />