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OP-336 Department of Revenue Services State of Connecticut PO Box 5031 Hartford CT 06102-5031 Nursing Home User Fee Amended Return Rev.12/09 Please type or print. Connecticut Tax Registration Number Federal Employer Identification Number FEIN Complete the return in blue or black ink only. Provider For calendar quarter ending Nursing home name DRS use only Number and street address PO Box City or town State General information If a nursing home o...
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