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PRINTED: 10/10/2012 FORM APPROVED Silent OF HEALTH AND HUMAN SERVICES., L.PIERS FOR MEDICARE & MEDICAID SERVICES OMB NO 09380391 (X1) PROVIDER/SUPPER/CL1A IDENT1PICATION NUMBER: STATEMENT OF DEFICIENCIES

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4 10 - Washington is a form used to report wages paid to employees and taxes withheld by an employer in the state of Washington.

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Information such as employer details, employee details, wages paid, and taxes withheld must be reported on 4 10 - Washington.

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