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PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES(X1) PROVIDER/SUPPLIER/LIGAND PLAN OF CORRECTIONIDENTIFICATION NUMBER:15563510/10/2017FORM
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Form state residential includes information about a person's residency status in a particular state.
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The purpose of included form state residential is to determine a person's residency status in a particular state for tax and legal purposes.
Information such as residency status, address, and any other details as required by the form instructions must be reported on included form state residential.
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