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PRINTED: 07/05/2016 FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA IDENTIFICATION

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Printed 0705 department is a form used for reporting certain tax information to the Department of Revenue.

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The information that must be reported on printed 0705 department includes details of taxable transactions or income, as specified by the Department of Revenue.