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MS-2126 Rev 07-07 NOTIFICATION OF FACILITY ADMISSION/DISCHARGE 1. RESIDENT INFORMATION Name: SSN: Date of Birth: Sex: Client ID #: Responsible Person or Agency: Relationship: Responsible Person Address:
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This form allows for reporting miscellaneous income.
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Individuals or entities who have received miscellaneous income.
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The purpose is to report miscellaneous income to the tax authorities.
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Details of the miscellaneous income received must be reported.
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