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PRINTED: 04/11/2011 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 0116 is a form used by the State Department of Revenue for reporting income received by certain entities in the state.

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Entities such as corporations, partnerships, and certain other business organizations are required to file printed 0116 if they have income sourced from within the state.

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