3 Public Ownership-Revised

Department of Health and Human Services, Health Resources and Services Administration, Healthcare Systems Bureau

OMB No. 0915-0327; Expiration Date: XX/XX/20XX

OFFICE OF PHARMACY AFFAIRS (OPA) HOSPITAL CERTIFICATION OF OWNERSHIP/OPERATION

BY A UNIT OF STATE/LOCAL GOVERNMENT

This certification must be completed and signed by representatives from the parties specified below acknowledging the eligibility requirement in section 340B(a)(4)(L)(i) of the Public Health Service Act regarding ownership/operation by a unit of state/local government.

Name of Hospital

Street Address, City, State, Zip

I certify that the aforementioned hospital organization is owned and/or operated by a unit of the State or local government. (Please check the appropriate box below.)

Owned Operated Both

State or Local Government Official Signature Date

Name of State or Local Government Official (please print or type)

Title and Unit of Government

Phone Number Ext. E-Mail Address

The undersigned certifies that he/she is fully authorized to legally bind the covered entity and certifies that the contents of any statement made or reflected in this document are truthful and accurate. The undersigned certifies that the ownership and/or operating status identified above is currently valid, and agrees to inform the Office of Pharmacy Affairs of any change as soon as possible.

Hospital Authorizing Official Signature Date

Name & Title of Hospital Authorizing Official (e.g.: CEO, CFO, COO) (Please print or type)

Phone Number Ext. E-Mail Address

This registration form must be completed and submitted according to the established deadlines that are published on the OPA website (www.hrsa.gov/opa).

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915-0327. Public reporting burden for this collection of information is estimated to average 2.0 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10C-26, Rockville, Maryland, 20857.