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PRINTED: 04/01/2021 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 1104 department is a form used to report income tax information for a specific department within an organization.
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The department head or authorized representative is required to file the printed 1104 department form.
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Income, deductions, credits, and other tax-related information must be reported on printed 1104 department form.
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