DocuSign Envelope ID: 35E34F09-3E3D-487F-9635-F663B8A519D5
Buena 1205305992
Park
CA
minheungki@gmail.com
102690
90621
12/01/2018
7142660378
Reference ID
CR-57909031372
CARES Act Provider Relief Fund
Tax ID Number: 831633883
Name as shown on your
income tax return: Heungki Min DDS A Professional Corp
Federal Tax Classification: S Corporation
Business Name (if different):
Street 1: 5881 Beach Blvd
Street 2:
State: CA
City: Buena Park
Zip: 90621
Registration Type: G
Group NPI (Group Only): 1205305992
(1) Contact Person Name: Heungki Min
(2) Contact Person Title: president
(3) Contact Person Phone
Number: 3107383117
(4) Contact Person Email: minheungki@gmail.com
(5) Applicant Type: de
IF FILING TIN INCLUDES FACILITIES
(6) Number of facilities: 1
(7) Beds for all facilities: 0
(8) Total number of FTE: 3
(9) CMS Certification
Number (CCN), if applicable:
REVENUES
(10) Gross Revenues:
(11) Fiscal Year of Gross Revenues:
(12) Percentage of Gross Revenue from Patient Care:
(15) Upload Gross Revenues
Worksheet (if required):
$ 300000
2019
100
(13) Lost Revenues due to COVID-19:
$ 30000
(14) Increased Expenses due to COVID-19:
$ 10000
(16) Upload Federal
Tax Form:
%
DocuSign Envelope ID: 35E34F09-3E3D-487F-9635-F663B8A519D5
ENTER PAYER MIX
(17) Medicare Part A + B: 0
%
(18) Medicare Part C: 0
%
(19) Medicaid: 20
%
(20) Commercial Insurer: 20
%
(21) Self-Pay: 10
%
(22) Other government payer: 50
%
(23) Other: 0
(24) Total:
%
100 %
0
(25) Total Amount received from Treasury SBA / PPP for Filing TIN and subsidiary TINs as of
5/31/2020:
(26) Total of payments received from FEMA for Filing TIN and subsidiary TINs as of 5/31/2020:
$ 15,212
$ 0
(27) Primary Provider FTE under filing TIN as of 5/31/2020:
1
(28) Non-Primary FTE under filing TIN as of 5/31/2020:
0
(29) Other FTE under filing TIN as of 5/31/2020:
2
(30) Number of Locations as of 5/31/2020:
1
(31) Upload FTE
Worksheet:
(32) Upload IRS Form 941
for Q1 2020:
BANKING INFORMATION
(33) Bank Name:
(34) ABA Routing Number: 121000358
Bank of America
(35) Account Holder Name: Heungki Min,DDS,A prof corp
(36) Account Number: 325005606595
OPTIONAL FIELDS
(37) Optional Field Code #1:
(38) Optional Field #1:
(39) Optional Field Code #2:
(40) Optional Field #2:
(41) Optional Field Code #3:
(42) Optional Field #3:
OPTIONAL UPLOADS
(43) Optional Upload Code #1:
(44) Optional Upload #1:
(45) Optional Upload Code #2:
(46) Optional Upload #2:
(47) Optional Upload Code #3:
(48) Optional Upload #3:
DocuSign Envelope ID: 35E34F09-3E3D-487F-9635-F663B8A519D5
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831633883
DocuSign Envelope ID: 35E34F09-3E3D-487F-9635-F663B8A519D5
DocuSign Envelope ID: 35E34F09-3E3D-487F-9635-F663B8A519D5
DocuSign Envelope ID: 35E34F09-3E3D-487F-9635-F663B8A519D5
DocuSign Envelope ID: 35E34F09-3E3D-487F-9635-F663B8A519D5
CARES Act Provider Relief Fund
FTE Worksheet (Form 1.0)
(1) Name as shown on your federal income tax return:
Heungki Min
(2) Taxpayer identification number (enter without dashes):
831633883
(3) Primary provider FTE -> Enter in Field (27) on the application form
1.00
(4) Primary provider (see instructions for Field 31) information as of 5/31/2020:
Number
Example
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