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Not needed if a health screen is attached. Applicant s name W-1487 Rev. 1/12 Name of facility Address Telephone Number Staff member Date Projected NH Admission Date Hospital Discharge Date CONNECTICUT HOME CARE PROGRAM FOR ELDERS HOME CARE REQUEST FORM The State of Connecticut wants to give you an opportunity to stay home instead of going to a nursing home.
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The State of Connecticut (CT) form typically refers to various tax forms or official documents required by the state's Department of Revenue Services for reporting income, business activities, or compliance with state regulations.
Individuals, businesses, and entities that have earned income or conducted business activities in Connecticut are required to file the appropriate state forms, depending on their specific tax obligations.
To fill out the State of Connecticut form, individuals should gather all relevant financial information, follow the instructions provided with the form, enter accurate data, and ensure all required signatures are included before submitting it to the appropriate state agency.
The purpose of the State of Connecticut form is to facilitate tax reporting, ensure compliance with state laws, collect revenue for public services, and gather necessary data for state budgeting and planning.
The information that must be reported on the State of Connecticut form typically includes personal identification details, income sources, deductions, credits, and other relevant financial information specific to the form being filed.
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