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FOR BHF USELL1
2012
STATE OF ILLINOIS
DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES
FINANCIAL AND STATISTICAL REPORT (COST REPORT)
FOR LONGER CARE FACILITIES
(FISCAL YEAR 2012)I.DPH License ID Number:
Facility
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Fax 630 is a form used to report certain information to the IRS.
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The purpose of fax 630 is to report certain information to the IRS for tax purposes.
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Fax 630 requires the reporting of specific financial information as outlined by the IRS.
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