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DocuSign Envelope ID: AA1647C8 -8778- 4021- 9E83- EDC4C913A37C
<br />Medicaid Transportation Provider Documentation
<br />North Carolina Orange County Department of Social Services
<br />Organization Information
<br />Organization Name as shown on income tax return, SHE - Oranne, LLC EIN 20- 8037463
<br />Doing Business As (DBA) information
<br />DBAName The Stratford EIN Same Former DSA Name(s) NIA EIN NIA
<br />Former OBA Name(s) NIA EIN NIA
<br />Years Doing Business under Current Name n0 08 Years Doing Business under Previous Names) NIA
<br />Ownership Information
<br />How would you describe the ownership? (circle one)
<br />Sole Proprietor Partnership Corporation Clty/Miunicipality Non - Profit
<br />For Corporation, Partnership, or Non - Profit: P lease provide ownership infonnatlon for each owner who has direct or indirect ownership
<br />or control Interest of 5% or more in the organization or entity.
<br />Owner 1
<br />Full Name (Last, first, Middle) WT AL Holdings, LL.0 SSN or EIN 81-3458026
<br />Date of Birth (MMIDDICCYY) NIA __ Business Relationship to NEMT Provider Sole Member
<br />Familial Relationship to NEW Provider (Mother, Father, Sister, Brother, None, etc.) None
<br />Owner 2
<br />Full Name (Last, first, Middle) SSN or EIN
<br />Date of Birth (MMIDDICCYY) Business Relationship to NEMT Provider
<br />Familial Relationship to NEW Provider (Mother, Father, Sister, Brother, None, etc.)
<br />Owner 3
<br />Full Name (Last, first, Middle) SSN or EIN
<br />Date of Birth (MMIDDICCYY) Business Relationship to NEW Provider
<br />Familial Relationship to NEW Provider (Mother, Father, Sister, Brother, None, etc.)
<br />Owner 4
<br />Full Name (Last, first, Middle) SSN or EIN
<br />Date of Birth (MMI❑❑ICCYY) Business Relationship to NEW Provider
<br />Familial Relatlonshlp to NEW Provider (Mother, Father, Sister, Brother, None, etc.)
<br />Managing Relationships
<br />As required by 42 CFR 1002.31 Non Emergency Medical Pfovlders must disclose the following for each individual officer, director, managing
<br />employee (general manager, business manager, administrator) and Electronic Funds Transfer (EFT) authorized Individual. Falture to provide the
<br />required Information may result in a denial for participaCon.
<br />Relationship 1
<br />Full Name (Last, first, Middle) Tret -ger, Charles Edward Jr. Social Security !Number 226.04 -4773
<br />Date of Blrth (MM1Dt71CCYY) 0712611958 _Business Relationship to NEMT Provider Manager
<br />Familial Relationship to NEMT Provider (Mother, Father, Sister, Brother, None, etc.) None
<br />Relationship 2
<br />Full !Name (last, first, Middle) Social Security Number
<br />Date of Birth (MMIDDICCYY) Business Relationship to NEW Provider
<br />Familial Relationship to NEW Provider (Mother, Father, Sister, Brother, None, etc,)
<br />DMA -3124 (revised 6!6112)
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