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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:15572802/17/2015FORM

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Printed 0217 is a document used by the Department of Revenue for reporting specific types of taxes or fees in certain jurisdictions.

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Entities or individuals who are subject to the taxes or fees represented by the printed 0217 are required to file this document.

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