Statement of Disclosure

I have not been:

1. Convicted of a felony offense;

2. Convicted of a misdemeanor offense involving an illegal substance within the five years previous;

3. Convicted of or entered a plea of guilty to a sex crime as defined in KRS 17:165

4. Convicted or entered a plea of guilty as a “violent offender” as defined in KRS 17.165: or

5. Accused and/ or substantiated by the Cabinet for Families and Children of an incident of abuse or neglect of a child or adult;

6. Excluded by the Office of Inspector General from providing federally funded health care programs including Medicare and Medicaid. I do hereby affirm that I meet all of the conditions listed above. I understand that dishonesty in my attesting of the above will result in immediate termination of my status as either a w-2 employee or a 1099 independent contractor or both. I also understand that that if this statement is found to be false that I will be at risk for recoupment of payment for services rendered