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PRINTED: 03/31/2020 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 0331 department is used for reporting tax information related to employment.
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Employee's name, Social Security number, wages, and tax withholding information must be reported on printed 0331 department.
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