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PRINTED: 11/22/2020 FORM APPROVED Indiana State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA IDENTIFICATION NUMBER:A. BUILDING: ___(X3) DATE SURVEY

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The printed 1111 department is a form issued by the IRS for reporting miscellaneous income.

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Anyone who has received miscellaneous income of $600 or more during the tax year.

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