TX HHS Form 1092. Change of Ownership Transfer Affidavit

Form 1092 is an official affidavit used to document and certify a Change of Ownership (CHOW) for facilities licensed and regulated in the state of Texas. This form is required when operational control of a licensed facility is transferred from one legal entity to another. It ensures that both the outgoing and incoming owners formally acknowledge the transfer, verify the accuracy of the information provided, and meet state licensing requirements. The affidavit must be completed accurately, signed by authorized representatives of both parties, and notarized before submission.

Purpose and Use of the Form

This form is used during the transfer of ownership for various healthcare and community service facilities regulated by Texas Health and Human Services (HHSC). The affidavit confirms the transfer of operational functions and supports compliance with Texas Administrative Code (TAC) requirements for CHOW procedures. Both parties involved in the transaction must certify the details of the ownership change and provide legally binding signatures in the presence of a notary.

Who Uses Form 1092

The form is required for licensed providers undergoing ownership transfer, including:

• Nursing Facilities (NF)
• Assisted Living Facilities (ALF)
• Day Activity and Health Services (DAHS)
• Prescribed Pediatric Extended Care Centers (PPECC)
• Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions (ICF/IID)
• Home and Community Support Services Agencies (HCSSA)

Both outgoing and incoming legal owners must participate in completing the affidavit.

Structure and Key Sections

Section 1 – Outgoing Owner

This section collects detailed information about the current legal entity operating the facility. It includes:

• Name of the legal entity responsible for facility operations
• Facility name or DBA
• License number
• Contract number (if applicable)
• Email address
• Mailing address

The outgoing owner must specify whether operational functions have been transferred or will be transferred to the incoming owner.

Section 2 – Incoming Owner

This section identifies the legal entity that will assume operation of the facility, as it will appear on the application for a new state license. Required information includes:

• Name of the new legal entity
• Facility name or DBA under the new ownership
• Effective date of the ownership change (past or future)

The form notes that changes to the effective date within 60 days do not require submitting a new affidavit, with guidance provided in Provider Letter 20-36 for nursing facilities.

Affirmations and Notary Requirements

Outgoing Owner’s Affirmation

The authorized representative must sign and affirm that all provided information is complete and correct. The section includes:

• Signature, printed name, title, and date
• Jurisdiction details (country, state/province, county)
• Notary acknowledgment, seal, and signature

Incoming Owner’s Affirmation

This section mirrors the outgoing owner’s affirmation and requires:

• Signature, printed name, title, and date
• Jurisdiction details for the incoming entity
• Notary acknowledgment and seal

Both affidavits must be completed in full and notarized to be valid.

Regulatory References

The form includes a table referencing the applicable CHOW rules in the Texas Administrative Code for each provider type:

• Nursing Facilities – 26 TAC §554.210
• Assisted Living Facilities – 26 TAC §553.35
• Day Activity and Health Services – 26 TAC §559.25
• Prescribed Pediatric Extended Care Centers – 26 TAC §550.108
• Intermediate Care Facilities (ICF/IID) – 26 TAC §551.16
• Home and Community Support Services Agencies – 26 TAC §558.23

Submission Instructions

Once completed and notarized, the affidavit must be uploaded to the Texas Unified Licensure Information Portal (TULIP). If the facility is contracted with HHSC, the provider must also notify their contract manager of the ownership change.

Form Details

• Form Name: Change of Ownership Transfer Affidavit
• Form Number: 1092
• Jurisdiction: Texas Health and Human Services
• Revision Date: August 2025