Ownership Attestation

Practice Information

Practice Name

Practice Address

Owner-Clinician Information

Full Name

Title (e.g., DDS, DMD, DVM)

Full Name

Title (e.g., DDS, DMD, DVM)

Full Name

Title (e.g., DDS, DMD, DVM)

By checking each box, you affirm the following under penalty of verification revocation:

The clinician(s) listed above hold ≥51% of the equity interest in the legal entity named above. The clinician(s) listed above actively see patients or clients at the practice on a regular basis.

Operational Control

I attest that no third-party entity — including any MSO, DSO, or private equity firm — controls the following:

Clinical treatment decisions and clinical protocols Clinical staffing decisions Fee schedules and pricing Clinical vendor and supply selection Patient communications and practice branding Financial distributions and bank account signatory authority No agreement exists that allows a third party to unilaterally terminate the clinician-owner(s)' operational control of the practice.

Acknowledgments

I understand that verification must be renewed annually. I will notify Locally Owned Care within 30 days of any change to ownership structure or operational control. I understand that if any statement in this attestation is found to be materially inaccurate, verification will be revoked.

Signature

Each owner-clinician listed above must sign individually.

Printed Name

Title (e.g., DDS, DMD, DVM)

Date

Signature

Type your name above or print this form and sign by hand.

Printed Name

Title (e.g., DDS, DMD, DVM)

Date

Signature

Type your name above or print this form and sign by hand.

Printed Name

Title (e.g., DDS, DMD, DVM)

Date

Signature

Type your name above or print this form and sign by hand.

Supporting Document

Email one of the following along with this attestation:

Schedule K-1 (Form 1065) with Part III redacted CPA letter confirming ownership percentage

Include with submission: Schedule K-1 (Part III redacted) or CPA letter confirming ownership %