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FOR OF USELL1
2001STATE OF ILLINOIS
DEPARTMENT OF PUBLIC AID
FINANCIAL AND STATISTICAL REPORT FOR
LONGER CARE FACILITIES
(FISCAL YEAR 2001)I.DPH Facility ID Number:
Facility Name:0022897II.IMPORTANT
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What is fax 847 674?
Fax 847 674 is a form used to report certain information to the relevant authorities.
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Individuals or entities who meet specific criteria as outlined in the form instructions are required to file fax 847 674.
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Fax 847 674 should be completed following the instructions provided on the form, ensuring that all required information is accurately reported.
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