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Health Financial Systems ADVOCATE GOOD SAMARITAN HOSPITAL In Lieu of Form CMS255210 This report is required by law (42 USC 1395g; 42 CFR 413.20(b)). Failure to report can result in all interim FORM

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What is 0 if line 5?

Line 5 is where you report your total income from all sources.

Who is required to file 0 if line 5?

Anyone who has income that needs to be reported to the tax authorities.

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You need to check all your sources of income and add them up to report on line 5.

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The purpose of line 5 is to accurately report your total income to the tax authorities.

What information must be reported on 0 if line 5?

All sources of income, including wages, bonuses, interest, dividends, and any other forms of income.

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