TX HHS Form 3725. Licensure Change of Ownership Affidavit

The Licensure Change of Ownership Affidavit (TX HHS Form 3725) is a crucial document that helps facilitate the transfer of ownership for facilities regulated by Texas Health and Human Services. This form is typically used in situations where the operational functions of a facility are being transferred from one owner to another, requiring official recognition and documentation.

The form requires key information about the outgoing and incoming owners, including their names as they appear on existing licenses or certifications. It also includes spaces for the transfer date, facility name, and identification number. The form must be notarized by a notary public before being submitted to the Texas Health and Human Services Commission.

After completing and notarizing the form, the original and one copy should be mailed to the commission at either P.O. Box 149030 or 701 W. 51st Street in Austin, TX. This ensures that all necessary documentation is received and processed efficiently. Key points to remember include:

• The form must be completed by both outgoing and incoming owners.
• The form requires notarization before submission.
• The original and one copy should be mailed to the Texas Health and Human Services Commission.