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PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES OMB NO. 09380391(X1) PROVIDER/SUPPLIER/LIGAND PLAN OF CORRECTION09/30/2011FORM APPROVEDIDENTIFICATION
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Individuals who are seeking to establish or prove their residency in a particular state or region may need to fill out the substantiated state residential form.
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Substantiated state residential is a form or document that verifies an individual's residency in a particular state.
Individuals who claim residency in a specific state for tax or legal purposes are required to file substantiated state residential.
To fill out substantiated state residential, individuals must provide their personal information, address, and any supporting documentation to prove their residency.
The purpose of substantiated state residential is to confirm an individual's legal residency in a particular state for tax and legal compliance purposes.
Information such as the individual's full name, address, date of residency, and any supporting documents validating their residency must be reported on substantiated state residential.
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