(Date Signed)
Chief Executive Officer Signature Name, CEO
(Date Signed)
Chief Financial Officer Signature Name, CFO
Performance Bond Annual Attestation Statement
Arizona Health Care Cost Containment System
I hereby attest that the Performance Bond documentation provided, consistent with 42 C.F.R. §§
438.604 and 438.606, herein is accurate, complete, and truthful. I understand that whoever knowingly
and willfully makes or causes to be made a false statement or representation on the documentation
may be prosecuted under the applicable state laws. In addition, knowingly and willfully failing to fully
and accurately disclose the information requested may result in denial of a request to participate, or
where the entity already participates, a termination of a Contractor's agreement or contract with the
Arizona Health Care Cost Containment System. Failure to sign this Attestation Statement, either by
written or electronic signature, will result in AHCCCS' non acceptance of the attached Performance
Bond.
FOR THE CONTRACT YEAR ENDED
