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DocuSign Envelope ID: AA1647C8 -8778- 4021- 9E83- EDC4C913A37C <br />Full Name (Last, firs 1, Middle) Social Security Number. <br />Date of Birth (MMIDD /CCYY) Business Relationship to NEW Provider <br />Familial Relationship to NEMT Provider (Mather, Father, Sister, Brother, None, etc.) <br />Relationship 4 <br />Full Name (Last, first, Middle) Social Security Number. <br />Date of Birth (MM1DD /CCYY) Business Relationship to NEW Provider <br />Familial Relationship to NEMT Provider (Mother, Father, Sister, Brother, None, etc. <br />By my signature, I attest that none of the Individuals Identified above have ever been convicted of: <br />• A criminal offense related to the delivery of an Item or service under Medicare, Medicaid, or any skate health care program; <br />• Medleare /Medlcald or any other healthcare program fraud; <br />• A conviction related to padent/client abuse; <br />• A felony conviction related to a controlled substance occurring after August 1996. r <br />Name Charles_ E._Tref7ger, Jr. Signature a <br />Date 06/04/18 <br />h!W://oig,hhs.gov/exclusions/index.as n <br />Results of OIG Federal Inquiry: <br />Circle One; No Match Found Organization or Business Owner Manager <br />Name of Individuallentlty which resulted in an exclusion match <br />Exclusion Code <br />Transportation Coordinator/Designee Signature <br />IittAS: //p roviderttacking ,dhhs,state.nc.us/defattlt,aspxx <br />Results of NC DHHS Provider Penalty Tracking Database <br />Circle One: No Match Found SSN Owner <br />Name of owner and/or S S N of owner which resulted In an exclusion match <br />Exclusion Reason (Action issued} <br />Transportation CoordinatorlDesignee Signature <br />/DMA -5124 (revised 615112) <br />