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PRINTED: 12/21/2020 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 1221 is a form used by the Department of Revenue for reporting specific tax information.
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Information such as income, deductions, and other financial details relevant to the tax period must be reported on printed 1221.
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