Section 420-D:4 - Disclosure StatementI. Each provider shall provide each prospective resident with a disclosure statement which has been approved by the commissioner. The disclosure statement shall be delivered before the initial transfer of funds or before any contract is consented to by each prospective resident of the facility. The disclosure statement shall include, in conspicuous large type, the statement: "NOTICE: You are advised to consult with an attorney before signing any documents or agreements concerning this matter. You have the right to cancel this agreement within 10 days after signing without obligation, except for certain described services and charges." The language of the disclosure statement shall be in plain and understandable English.II. The disclosure statement shall include the following information: (a) The name of the organization and whether it is for profit, and whether it is a partnership, corporation, or other type of organization.(b) For all officers, trustees, investors, and owners with more than 5 percent ownership and for the facility manager: (1) Name, address and amount of ownership.(2) Responsibility and relationship to the facility.(3) Previous experience with similar facilities.(4) Previous business experience.(5) Any felony convictions against such person in any jurisdiction.(6) Any court orders or injunctive relief against such person.(7) Relationships with other nursing homes or like communities.(8) Previous bankruptcies or financial actions against such person.(9) Relationship with any supplier or potential supplier of services.(10) Supplies or materials of any kind contributed or sold to the provider.(c) The provider's relationship with any religious, charitable, or nonprofit organization and the extent of such organization's financial responsibilities to the provider or to residents. (d) Whether the provider claims to be nonprofit or tax exempt.(e) The location and description of the facility and, if it is proposed or incomplete, the estimated completion date, status of construction, and any contingencies on that completion date.(f) Those services to be provided by the facility under basic contract and those at extra cost.(g) All locations where services are to be provided, if different from the main facility.(h) All entrance fees and periodic payments that are required of residents and a description of all policies and conditions for refund or return of these fees and payments.(i) When and how periodic payments may be changed by the facility.(j) Provisions of the provider for reserve funding, escrows, and trusts and investment of these funds.(k) Financial statements audited by a certified public accountant including, if the facility is in operation, a balance sheet and an income statement for the 2 complete and immediately preceding years.(l) If the facility has not yet begun operating: (1) All expected costs or obligations.(2) Full description of all mortgages or long term financing and an analysis of the occupancy rates necessary to pay them together with an analysis showing the number of contracts necessary to make start-up feasible.(3) Estimated entrance fee income prior to operation.(4) Estimated start-up losses and reserves to be covered by entrance fees.(5) Projection of estimated annual income from periodic payments.(6) Resident mortality and morbidity assumptions.(7) Analysis of facilities expected to compete with the proposed facility and a demographic analysis of the elderly population expected to support the facility.(8) All periodic payments a resident will be expected to pay.(9) Assumptions and bases for estimating occupancy rates.(10) All expected subsidies, private or government, including Medicaid and Medicare, and the effect if these subsidies are not received.(11) Projected annual operating expenses.(12) Estimated capital and equipment replacement expenditures for the current year and the next 5 years. In specific cases, the commissioner may, if he deems necessary, require a longer period of projection of the estimated capital and operating expenses.(13) All assets pledged as collateral.(14) Annual payments on long term financing.(15) Any other commitments over $25,000 to make payments to another party for any purpose.III. The disclosure statement shall contain any other information deemed necessary by the commissioner.IV. The cover page of the disclosure statement shall state, in a prominent location and type face, the date of the disclosure statement and that the issuance of a certificate of authority does not constitute approval, recommendation, or endorsement of the facility by the department, nor is it evidence of, nor does it attest to, the accuracy or completeness of the information set out in the disclosure statement.1988, 44:2, eff. Jan. 1, 1989.