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01/26/2018PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICESFORM APPROVEDCENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES(X1) PROVIDER/SUPPLIER/LIGAND PLAN OF CORRECTIONIDENTIFICATION
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January 2-3-4 is a form used for reporting miscellaneous income such as rents, royalties, prizes, awards, and medical payments.
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The purpose of January 2-3-4 is to report miscellaneous income to the IRS and the recipient of the payment.
Information such as the recipient's name, address, and Social Security number, as well as the amount of income paid and the purpose of the payment, must be reported on January 2-3-4.
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