APPLICATION TO REGISTER A

BUSINESS TO BE CONDUCTED UNDER A TRADE NAME

STATE OF GEORGIA

COUNTY OF TIFT

The undersigned hereby certifies that they are conducting a business at 706 North Parrish Avenue, in the city of Adel, County of Cook, state of Georgia under the name: COOK SENIOR LIVING CENTER and that the type of business to be conducted is health care services and that said business is composed of the following persons: Tift County Hospital Authority, 901 E. 18th Street, Tifton, GA 31794. This affidavit is made in accordance with the Official Code of Georgia annotated, Title 10, Chapter 1, Section 490.

William T. Richardson, Applicant

Dennis L. Crum, Applicant

Sworn to and subscribed before me this 18th day of June, 2012.

Bonnie Roberson, Notary Public

Lennis H. Storey, Deputy Clerk

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