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DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F62548 (01/2020)STATE OF WISCONSINASSISTED LIVING FACILITY WAIVER, APPROVAL, VARIANCE OR EXCEPTION REQUEST When this request is submitted,
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This request pertains to the filing of specific tax documentation required by the IRS for income reporting.
Individuals or businesses that meet the income thresholds set by the IRS must file this request.
The form should be completed accurately with all required information, including income details and taxpayer identification.
The purpose is to report income to the IRS and ensure compliance with federal tax laws.
Information such as total income, deductions, and credits must be reported on this request.
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