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FMS Provider Services P.O. Box 479, East Windsor, CT 060880479 Phone: (860) 6279500 Fax: (860) 6270230 Toll Free: (877) 7228833 ABI APPLICATION SUPPLEMENT: Agency Employee This form is provided to

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This form is provided for reporting income tax information.

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Individuals, businesses, and other entities with taxable income are required to file this form.

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The purpose of this form is to report income, deductions, and tax liability to the IRS.

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Income, deductions, credits, and tax payments must be reported on this form.