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PRINTED: 05/10/2019 FORM APPROVEDDivision of Health Service Regulation STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION A.

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What is our house?

Our house is the primary residence where we live.

Who is required to file our house?

The owner or owners of the house are required to file.

How to fill out our house?

Our house can be filled out by providing information about the property, ownership details, and any changes in the property status.

What is the purpose of our house?

The purpose of our house is to provide an accurate record of primary residences for tax and government purposes.

What information must be reported on our house?

Information such as property address, ownership details, and any changes in property status must be reported.

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