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PRINTED: 11/02/2021 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 1104 form is a tax form approved by the Internal Revenue Service (IRS) for reporting certain types of income.
Individuals or businesses who have received income that is required to be reported on the 1104 form are required to file.
The 1104 form can be filled out manually or electronically, following the instructions provided by the IRS.
The purpose of the 1104 form is to report specific types of income to the IRS for tax purposes.
Information such as name, address, Social Security number, and details of the income received must be reported on the 1104 form.
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