Texas Department of Aging Form 3604
and Disability Services March 2010
Ownership Transfer Affidavit
1. Name of Legal Entity Responsible for Operation of the Facility (as it appears on existing contract)
Facility Name (DBA, as it appears on existing contract) Contract No.
HAS TRANSFERRED WILL TRANSFER all operational functions of this facility to:
2. Name of Legal Entity Responsible for Operation of the Facility (as it will appear on contract and on Application for State License)
Facility Name (DBA, as it will appear on contract and on Application for State License)
Date
3. The effective date of the change WAS WILL BE ....................................................................
Date (DADS Use Only)
4. The date of official DADS recognition is (DADS use only) .....................................................................
OUTGOING OWNER: The parties understand and agree that the OUTGOING OWNER is responsible to DADS for any overpayment
that may have accrued during the outgoing owner's period of ownership or responsibility. Any underpayments due the OUTGOING
OWNER up to the ownership change date should be mailed to the address below:
Name Telephone No. (inc. A/C)
( )
Address (Street or P.O. Box, City, State, ZIP Code)
IMPORTANT NOTE TO OUTGOING OWNER: The above address will be used for ALL correspondence mailed to you
pertaining to this facility. If a change of address occurs, please contact DADS, Institutional Services (W-535), P.O. Box
149030, Austin, TX 78714-9030. If you want to set up a direct deposit account for your final payment or if changes in your
financial institution occur, please contact DADS, Fiscal Division (E-411), P.O. Box 149030, Austin, TX 78714-9030.
The incoming owner's right to contractor payment begins only after the incoming owner has obtained a new, fully executed
contract with DADS.
Outgoing Owner–(name of legal entity as it appears on existing contract) Incoming Owner–(name of legal entity as it will appear on contract)
Signature–Authorized Representative of Outgoing Owner Signature–Authorized Representative of Incoming Owner
(as per Form 2031 or Form 2031-G) (as per Form 2031 or Form 2031-G)
Name (please type or print) Name (please type or print)
Title Date Title Date
Note: Complete the form and have it notarized. Mail original and one copy to the address given below:
Texas Department of Aging and Disability Services OR Texas Department of Aging and Disability Services
Institutional Services (W-535) (For Overnight Shipments Only) Institutional Services (W-535)
P.O. Box 149030 701 W. 51st Street
Austin, TX 78714-9030 Austin, TX 78751
Form 3604
Page 2 / 03-2010
Outgoing Owner's Affirmation
Country, Territory or Nation .......
State or Province .......................
County of ...................................
Before me, the undersigned authority, on this day personally appeared ,
known to me to be the person(s) whose name(s) is (are) subscribed to the foregoing instrument and who being duly sworn
by me, state(s) that the above and foregoing information supplied in this instrument is complete, true and correct.
Subscribed and sworn before me, , a Notary Public for this state
(or province) on the day of , 20 .
(Notary Seal)
Notary Public
Incoming Owner's Affirmation
Country, Territory or Nation .......
State or Province .......................
County of ...................................
Before me, the undersigned authority, on this day personally appeared ,
known to me to be the person(s) whose name(s) is (are) subscribed to the foregoing instrument and who being duly sworn
by me, state(s) that the above and foregoing information supplied in this instrument is complete, true and correct.
Subscribed and sworn before me, , a Notary Public for this state
(or province) on the day of , 20 .
(Notary Seal)
Notary Public