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Consumer Request Form
This form only applies to California and Colorado residents. Are you a California or Colorado resident?*

This form only applies to California and Colorado residents.

REVENUE AND TAXATION CODE - RTC
DIVISION 2. OTHER TAXES [6001 - 61050] (Heading of Division 2 amended by Stats. 1968, Ch. 279.)
PART 10. PERSONAL INCOME TAX [17001 - 18181] (Part 10 added by Stats. 1943, Ch. 659.)

CHAPTER 1. General Provisions and Definitions [17001 - 17039.3] (Chapter 1 repealed and added by Stats. 1955, Ch. 939.)

17014. (a) “Resident” includes:

(1) Every individual who is in this state for other than a temporary or transitory purpose.

(2) Every individual domiciled in this state who is outside the state for a temporary or transitory purpose.

(b) Any individual (and spouse) who is domiciled in this state shall be considered outside this state for a temporary or transitory purpose while that individual:

(1) Holds an elective office of the government of the United States, or

(2) Is employed on the staff of an elective officer in the legislative branch of the government of the United States as described in paragraph (1), or

(3) Holds an appointive office in the executive branch of the government of the United States (other than the armed forces of the United States or career appointees in the United States Foreign Service) if the appointment to that office was by the President of the United States and subject to confirmation by the Senate of the United States and whose tenure of office is at the pleasure of the President of the United States.

(c) Any individual who is a resident of this state continues to be a resident even though temporarily absent from the state.

(d) For any taxable year beginning on or after January 1, 1994, any individual domiciled in this state who is absent from the state for an uninterrupted period of at least 546 consecutive days under an employment-related contract shall be considered outside this state for other than a temporary or transitory purpose.

(1)For purposes of this subdivision, returns to this state, totaling in the aggregate not more than 45 days during a taxable year, shall be disregarded.

(2)This subdivision shall not apply to any individual, including any spouse described in paragraph (3), who has income from stocks, bonds, notes, or other intangible personal property in excess of two hundred thousand dollars ($200,000) in any taxable year in which the employment-related contract is in effect. In the case of an individual who is married, this paragraph shall be applied to the income of each spouse separately.

(3)Any spouse who is absent from the state for an uninterrupted period of at least 546 consecutive days to accompany a spouse who, under this subdivision, is considered outside this state for other than a temporary or transitory purpose shall, for purposes of this subdivision, also be considered outside this state for other than a temporary or transitory purpose.

(4) This subdivision shall not apply to any individual if the principal purpose of the individual’s absence from this state is to avoid any tax imposed by this part.

(Amended by Stats. 1994, Ch. 1243, Section 4. Effective September 30, 1994.)

Code of Colorado Regulations – Colorado Resident

Regulation 39-22-103(8)(A) RESIDENT INDIVIDUAL

(1) General Rule. A natural person is a resident individual of Colorado if either. (a) The person is domiciled in Colorado, or (b) The person satisfies the six-month rule (statutory residency rule).

(2) Domicile. (a) General Rules regarding Domicile. (i) A person’s domicile is in Colorado if the person’s place of abode is in Colorado and that person, whenever absent, has the present intention of returning after a departure or absence, regardless of the duration of the absence. A place of abode is not limited to a specific structure, but rather refers to a place or area to which the person expects to return. (ii) An intention to initially establish domicile without being physically present in the intended domicile is insufficient to establish a domicile in such place. (iii) A person can have only one domicile at any given instant, even if such person has homes in more than one state. See, paragraph (2)(d) regarding having more than one domicile during the same tax year.

CODE OF COLORADO REGULATIONS 1 CCR 201-2 Taxpayer Service Division - Tax Group 2

(iv) A person who is domiciled in a state remains a domiciliary of that state even if the person temporarily resides outside that state. (v) Once a person’s domicile is established in a state, it will continue to be the person’s domicile until the person establishes domicile in another state. (vi) A determination of residency or domicile by a Colorado state or local government agency for non-tax purposes is not a determination of domicile for purposes of Colorado income tax. (b) Intent to Establish Domicile. The intent to establish a domicile is essential in the determination of a person’s domicile. (i) Because a person’s subjective intent is difficult to determine, a person’s intention is determined only by objective, verifiable evidence. The indicia of domicile and presumptions set forth in paragraphs (2)(c) and (4), below, will determine a person’s domicile, unless there is sufficient objective evidence to overcome the presumptions. (ii) A person’s reason for changing domicile, including to take advantage of tax benefits of a place of abode, is irrelevant so long as the person has an absolute and fixed intention to abandon one domicile and acquire another. For example, a person can lawfully establish domicile in Nevada solely for the purpose of living in a state with no income tax, but whether that person truthfully has a present intention to establish domicile in Nevada and abandon their domicile in Colorado is a matter of proof. (c) Indicia of Domicile. The Department will consider a number of factors to determine a person’s domicile. These factors include, but are not limited to: (i) Place of domicile in prior years; (ii) Length of time in a purported domicile. Although domicile can be established on the first day that a person is physically present in a state, the greater the length of time a person is present in a place tends to indicate that place is the person’s domicile; (iii) Location of, and length of time residing in, a place of abode by a spouse or dependent children; (iv) Jurisdiction that issued person’s current driver’s license; (v) Jurisdiction where motor vehicle is registered; (vi) Jurisdiction where person is registered to vote; (vii) Employment status, including whether employment or employment duties in the state are permanent or temporary and the location where the person performs most of their employment duties. (viii) In the case of a sole proprietorship or other entity under the control of the person, the location of business assets owned by the person or by an entity controlled by the person;

CODE OF COLORADO REGULATIONS 1 CCR 201-2 Taxpayer Service Division - Tax Group 3

(ix) Receipt of government benefits, such as unemployment benefits, welfare, and other government benefits; (x) Location of living accommodations; (xi) Jurisdiction that issued a professional license; (xii) Jurisdiction where person filed a resident or nonresident individual state income tax return; (xiii) Statements of residency made publicly, to third parties, and in documents, including applications for insurance, federal income tax forms, or social media comments, particularly if such statements are contrary to the person’s interests; (xiv) Primary mailing address for financial documents and other important correspondence; (xv) Business and social ties to the community, including child’s school, location of family, business memberships, religious institution membership and social memberships; (xvi) Location of primary care physician and dentist; (xvii) Location of real property owned or controlled by the person and the attributes of such property, such as size, value, and purposes for which it is used; (xviii) Location of personal property and its attributes, such as monetary and sentimental value and whether it was located in prior place of domicile. No one factor is determinative and not all factors may be relevant or equally weighted. For example, a person may register a vehicle where their vacation home is located and where the vehicle is primarily used, but that registration does not, by itself, create domicile. The amount of time spent in one place also does not always explain the difference between temporary home and domicile. A person may live in a temporary home or residence for months or years on a temporary work assignment or to attend school and maintain domicile in another state. The person’s intent as shown by objective facts is the primary factor used to determine domicile. (d) Periodic and Seasonal Changes in Domicile. (i) In limited cases, a person may periodically or seasonally abandon their domicile in one state and establish domicile in another. For example, a person who has a house in Colorado and Arizona and who seasonally moves from one home to another, may be a domiciliary of Colorado and Arizona for different parts of a tax year if the person treats both homes as their primary place of abode for the season. (ii) A person who lives in a motorized home and does not own or lease residential real property that they treat as their home in another state will be treated as a (full-year) domiciliary of Colorado if they have permanent ties to the state and spend, in the aggregate, more time in this state than in any other. However, a person who owns a home in another state but travels seasonally or periodically to Colorado will not, in the absence of other factors, be treated as a domiciliary of Colorado.

CODE OF COLORADO REGULATIONS 1 CCR 201-2 Taxpayer Service Division - Tax Group 4

(e) Status as a student. A student who moves to another state to attend college but who does not intend to remain in that state after graduation has not changed domicile. Moreover, a student who is being supported by a parent or parents does not establish a domicile separate from the parent(s) simply by attending school in another state regardless of whether the student takes such steps as acquiring a driver's license or registering to vote in the state in which he or she attends school. (f) Resident Aliens. A person who is not a citizen of the United States but is a permanent resident alien may establish a domicile in Colorado. A person on a temporary visa is not a domiciliary. However, he or she may be a resident under the six-month rule. (3) Six-Month Rule or Statutory Resident Rule. (a) A person satisfies the six-month rule if: (i) The person maintains a permanent place of abode in Colorado, and (ii) Spends, in the aggregate, more than six months of the taxable year in Colorado. (b) This six month rule does not apply to: (i) A member of the armed forces who is stationed in Colorado pursuant to an order of the armed forces (see, Servicemembers Civil Relief Act of 2003 (50 USC App. § 501-597b)); (ii) A Colorado domiciliary who abandons their Colorado domicile during the tax year and does not maintain a permanent place of abode in Colorado after abandoning their domicile; (iii) A person who is domiciled outside Colorado and establishes their domicile in Colorado during the tax year, unless that person has a place of abode in Colorado while maintaining a domicile outside Colorado; (iv) A student whose domicile is not Colorado and attends college in Colorado but does not have a permanent place of abode in Colorado. (c) A “permanent place of abode” means any place in which a person has a possessory right to live. (i) The person need not own the permanent place of abode. For example, a lease of an apartment can constitute a permanent abode. (ii) A recreational vehicle with sleeping and cooking accommodations can constitute a permanent place of abode. (iii) A person need not be liable for the lease or mortgage obligation for the permanent place of abode. For example, a person, whose domicile is in another state and whose employer leases an apartment in Colorado for the person to reside while on a temporary assignment in Colorado, has a permanent place of abode in Colorado. (d) The six month rule applies even if the person is a domiciliary of another state. For example, a person who is not domiciled in Colorado is a resident individual of Colorado for Colorado income tax purposes if the person maintains a permanent place of abode in Colorado and lives during the tax year, in aggregate, more than six months in Colorado.

CODE OF COLORADO REGULATIONS 1 CCR 201-2 Taxpayer Service Division - Tax Group 5

(4) Burden of Proof and Presumptions. The burden of production and persuasion (collectively referred to in this rule as the burden of proof) is on the person asserting a change of domicile or rebutting a presumption. Whether the burden of proof has been met will be determined based only on objective evidence and cannot ordinarily be established by subjective evidence (e.g., self-serving statements of intent unless such statements are against one’s interest). (a) The place where one currently lives is presumed to be the person’s current domicile. (b) Once a domicile is established, it is presumed to continue in such place. (c) Spouses are presumed to have the same domicile or permanent place of abode. This presumption does not apply after spouses are separated, even though no judgment or decree of separation or divorce has been rendered. (d) A person in the armed forces does not, as a matter of law, abandon his or her domicile solely by reason of being absent from their state of domicile pursuant to orders of the armed services. However, such a person is not precluded from changing their domicile. (e) A minor child and a dependent are presumed to have the same domicile or permanent place of abode as the custodial parent or custodial guardian. A minor child cannot, by their acts or intentions, change domicile. (f) A person who is domiciled in Colorado and who leaves this state to accept a job assignment in a foreign nation is presumed not to have abandoned their Colorado domicile. (g) The six-month rule does not create a presumption that a Colorado domiciliary not physically present in Colorado for more than six months has abandoned their Colorado domicile. (h) The domicile of a person in the armed forces will initially generally be determined by the facts existing immediately prior to becoming a member of the armed forces. (i) Presumptions regarding permanent place of abode. (i) The mere ownership or leasing of real property in a jurisdiction is not presumed to be a place of abode in that jurisdiction. (ii) A place of abode owned by an individual who leases it to others, not related to the owner or their spouse by blood or marriage where the individual has no right to occupy any portion of the premises and does not use such premises as their mailing address during the term of the lease is presumed not to be a permanent place of abode. (iii) A recreational vehicle camp lot or camp ground without a hookup is presumed not to be a permanent place of abode. (iv) A motel room or any construction which does not contain facilities ordinarily found in a place of abode, such as facilities for cooking, bathing, etc., is generally not deemed a permanent place of abode. (v) A rented apartment, house, or condominium of an individual on a temporary work assignment in a state that returns to their state of domicile when they are not working (e.g. weekends) is generally not deemed a permanent place of abode.

CODE OF COLORADO REGULATIONS 1 CCR 201-2 Taxpayer Service Division - Tax Group 6

(vi) An apartment, house, or condominium in a state paid for by an employer in a location that is not the person’s domicile is not considered a permanent place of abode if the person is in the state on a temporary work assignment. For example, an individual domiciled in another state may reside in an apartment in Colorado while on temporary assignment for the employer, after which the person will return to their domicile. If the employer pays for an apartment in Colorado while the employee is on a temporary work assignment in Colorado, the apartment does not constitute a permanent place of abode. However, if the employee pays for an apartment while on a temporary work assignment in Colorado and remains in Colorado when not working, the employee’s apartment is a permanent place of abode. Cross References 1. See IRS Publication 555 “Community Property” regarding the definition of domicile. 2. See Department Rule 39-22-108(3)(b) for special rules relating to persons in the military and their spouses. 3. People v. White 242 P.3d 1121 (2010), (“The current principal-or-primary-home test for voting purposes, largely adopted by the legislature in 1979 and now expressly made applicable to motor vehicle and income tax matters as well, however, clearly resolves this ambiguity [pertaining to the meaning and proof of “residence”] in favor of an objectively determined “legal residence” or domicile.”) 4. §1-2-102(1)(a)(I), C.R.S. 5. Texas v. Florida, 307 U.S. 398 (1939)

Regulation 39-22-103(8)(B) MILITARY SERVICEMEMBER RESIDENT INDIVIDUAL

(1) Servicemember. A servicemember whose domicile is Colorado and who spends at least 305 days of the tax year stationed outside of the fifty-state boundary of the United States of America, the District of Columbia or a United States possession on active military may, but is not required to, elect for that tax year to be treated as a nonresident of Colorado for Colorado income tax purposes. The servicemember makes this election on their Colorado income tax return. (2) Servicemember Spouse. The spouse of a servicemember described in paragraph (1), above, may also, but is not required to, elect to be treated as a nonresident of Colorado for purposes of Colorado income tax for the tax year if: (a) the spouse spends at least 305 days of the tax year outside the United States and District of Columbia or a United States possession for the purpose of accompanying their spouse, and (b) the servicemember elects, pursuant to paragraph (1), above, to be treated as a nonresident of Colorado. (3) The 305 days do not have to be consecutive days, but all 305 days must occur within the tax year for which the election is made. Cross References 1. See, Department Rule 39-22-103(8)(a) for information on what constitutes a Colorado resident.

California Consumer Privacy Act (CCPA) of 2018 as Amended by the California Privacy Rights Act (CPRA)
California Resident Consumer Request Form

Verification Process

This is a process to determine that the consumer making the request is the consumer about whom we have collected the personal information. In order to verify your identity we will, whenever feasible, match the identifying information you provide to the personal information we already maintain and/or use a third-party identity verification service. To do this we require the following information from you:

  • Request to Know What Categories of Personal Information is Being Collected. Provide your name and email address below.
  • Request to Know the Specific Pieces of Personal Information Collected: Provide your name, email address, date of birth, phone number and home address below. Also submit a signed Declaration Form under penalty of perjury verifying your identity.
  • Request to Delete: Provide your name, email address, date of birth, phone number and home address below. Also submit a signed Declaration Form under penalty of perjury verifying your identity.
  • Request to Correct Inaccurate Personal Information: Provide your name, email address, date of birth, phone number and home address below. Also submit a signed Declaration Form under penalty of perjury verifying your identity.
  • Request to Limit the Use and Disclosure of Sensitive Personal Information: Provide your name and email address below.
  • Request to Opt-Out of the Sale or Sharing of Personal Information: Provide your name and email address below.
  • Right to Opt-In. You may choose to opt-in after opting-out of the sale or sharing of your Personal Information if a Service requires the sale or sharing of your Personal Information.

Required fields are marked with an asterisk *

Authorized Agents

Please indicate here if you are acting as an authorized agent :*
If yes, which of the following applies to you:*

Send authorizing documentation to CORP.PersonalInformationRequest@HCAHealthcare.com.

California Consumer Request

Full Name (First, Middle, and Last)*

Zip Code*
Date of Birth:*
Are you a current or former employee, applicant, independent contractor, medical staff, owner, director, officer, a beneficiary or an emergency contact?*
How would you like us to respond to your request?*
Please indicate what type of request(s) you would like to make:
Please indicate which request(s) you would like to make according to the definitions in the privacy policy: *

Minors

We do not have actual knowledge that we sell or share the Personal Information of Consumers who are less than 16 years of age. However, if we have actual knowledge that the Consumer is less than 16 years of age, we will not sell or share the Consumer’s Personal Information unless the Consumer in the case of Consumers who are at least 13 years of age and less than 16 years of age, or the Consumer’s parent or guardian, in the case of Consumers who are less than 13 years of age, has affirmatively authorized the disclosure of the Consumer’s Personal Information.

Timing

We will respond to Requests to Know or Access Personal Information, Request to Know the Specific Pieces of Personal Information Being Collected, Requests to Delete Your Personal Information and Requests to Correct Inaccurate Personal Information no later than 45 calendar days after we receive the request, unless we need more time in which case we will notify you and may take up to 90 days total to respond to your request. We will respond to Requests to Opt-Out of the Sale or Sharing of your Personal Information and Requests to Limit the Use and Disclosure of Sensitive Personal Information no later than 15 calendar days after we received your request.

Requests for a Minor

Are you submitting a request for a minor?*

Parental Consent Form

Custodial Parent/Guardian Full Name*

Zip Code*
Custodial Parent/Guardian Date of Birth *
Minor's Full Name*
Minor's Address*
Address 2
City*
Zip Code*
Minor's Date of Birth*

I do hereby declare, under penalty of perjury under the laws of California and the United States, that I am the parent or legal guardian of the minor (consumer) whose personal information is the subject of the Request.

Date of Consent*
The parties agree that this form is an agreement that may be signed electronically. By completing and submitting this form you consent to the use of electronic signatures. Such signature shall be treated the same as a traditional handwritten signature.

Declaration of Consumer

I,

a resident of California, in connection with my request to opt-in to the sale or sharing of my personal information, to receive the specific pieces of personal information collected about me, to correct inaccurate personal  information or to delete personal information collected from me since January 1, 2022 (the "Request") by HCA Healthcare, Inc., do hereby declare, under penalty of perjury under the laws of California and the United States, that I am the consumer whose personal information is the subject of the Request.

This Declaration is made as of this date*

The parties agree that this form is an agreement that may be signed electronically. By clicking on the "Submit" box below, this action confirms the parties' consent to the use of electronic signatures and such action shall be treated the same as a traditional handwritten signature.

To obtain a copy of this form click the "Print" button below before clicking "Submit"

Colorado Privacy Act (CPA) - Consumer Data Request Form

Required fields are marked with an asterisk *

Authorized Agents

Please indicate here if you are acting as an authorized agent: *
If yes, which of the following applies to you:*

Send authorizing documentation to CORP.PersonalInformationRequest@HCAHealthcare.com.

Please provide the following information

Full Name (First, Middle, and Last)*

Zip Code*
Date of Birth:*
Please indicate what type of request(s) you would like to make:*

Timing

We will respond to your request(s) no later than 45 calendar days after we receive the request, unless we need more time in which case we will notify you and may take up to 90 days total to respond to your request(s).

Requests for a Minor

Are you submitting a request for a minor?*

Parental Consent Form

Custodial Parent/Guardian Full Name*

Zip Code*
Custodial Parent/Guardian Date of Birth *
Minor's Full Name*
Minor's Address*
Address 2
City*
Zip Code*
Minor's Date of Birth*

I do hereby declare, under penalty of perjury under the laws of Colorado and the United States, that I am the parent or lawful guardian of the minor (consumer) whose personal information is the subject of the Request.

Date of Consent*
The parties agree that this form is an agreement that may be signed electronically. By clicking on the "Submit" box below, this action confirms the parties' consent to the use of electronic signatures and such action shall be treated the same as a traditional handwritten signature.

To obtain a copy of this form click the "Print" button below before clicking "Submit"