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PRINTED: 04/15/2021 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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The 0414 form is a tax document used to report income and expenses related to a specific business activity.

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Individuals or businesses engaged in the specific business activity for which the form is designed are required to file the 0414 form.

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The purpose of the 0414 form is to report income and expenses accurately for tax purposes related to the specific business activity.

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You must report detailed information about your income and expenses related to the specific business activity, including dates, amounts, and any relevant supporting documentation.

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