Form CMS-10169 Change of Ownership (CHOW) Contract Supplier Notificatio

CHANGE OF OWNERSHIP - CONTRACT SUPPLIER NOTIFICATION FORM
Per Article V of the DMEPOS competitive bidding contr act and §414.422( d)(l), a contract .supplier is obligated to notify CMS at least 60 calendar day s
befor e the anticipated date of a change of owne-r ship ( CHOW). Failur e to notify C MS may r esult in a breach of contract.
The purchasing supplier must also complete the Change of Owner ship Purchaser for m and submit it to the Competitiv e Bidding Implementation
Contractor ( CBIC) along with other r equir ed documents at least 30 calendar day s prior to the effective date of the CHOW. The only ex ception to this
r equir ement is when a contr act supplier is purchasing a non -contract supplier. In this situation, the contract supplier should complete the Contract
Supplier Location Update For m as applicable in addition to this for m .

If a contr act supplier holds multiple contracts ( in a single r ound or in multiple rounds) and is involv ed in a change of owner ship, a Contr act Supplier
Notification Form mu-s t be submitted for each contr act number.

* - denotes r equir ed

fields

Anticipated Date of Change of Ownership"'

Role of Contract Supplier:*

r

Purcha-sing another contract .supplier

@'t Purchasing a non- contract supplier

This form is not r e quire d \IJhe n a contr act supplier is purchasing a non -contract supplier. To add or remove locat ions f rom
your contract, please use the Contract Supplier Location Update f orm.

r

Selling to another contract supplier

C

Selling to a non- contract supplier

Resulting Entity:*

r

Successor Entity (Company A

C

New Entity ( Company A + Company B

B = Company
= Company C)

+ Company

A)

Type of Purchase:*

r
r

Asset - purchase of assets without assuming liabilities
Asset and liabilities - purchase of assets and assuming the liabilities of the seller

~ Stock only - purchase of corporate stock ( as in shar es possessed by

a stockholder)

A sale of cor por ate stock ( as in shar es pos-s essed by a st ockholder) does not constitute a change of ownership. This for m is for r eporting
change-s of ownership that r equir e the submi.ssion of a nov ation agr eem ent for CMS appr ov al. Please use the Change of Location and t he
Change of Infor mation for ms to update y our infor mat ion.

Are you planning to change the structur e of y our business? (Ex. fr om a partnership to an LLC)

C

Yes

r.. No

Is the contract supplier currently affiliated with another contract supplier through a previous change of ownership? "'
Does the contract supplier hold multiple contracts (either in a single round or in multiple rounds)? *

C

r

Yes

r

No

Yes (" No

Seller Information

r

Contract Supplier:*

Yes r • No

Seller·s legal Business Name"'

Contract No. (if applicable)

13 Doing Business As Name *

Authorized Official Contact Telephone No.*

I

r

File Typeapplication/pdfFile Modified2013-03-01File Created2013-03-01