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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:15G32801/04/2013FORM

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Printed 0104 refers to the tax form used by the Department of Revenue for individual income tax filing in certain jurisdictions.

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The purpose of printed 0104 is to report individual income, calculate tax liability, and ensure compliance with state income tax laws.

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The information that must be reported includes personal identification details, income earned, applicable deductions, credits, and the calculated tax owed.

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