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PRINTED: 04/02/2018 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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What is printed 0402 - form?

The printed 0402 - form is a tax form used for reporting certain types of income.

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Individuals and businesses who have received income that needs to be reported on the form.

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The purpose of the form is to report income to the tax authorities for proper tax assessment.

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Income details such as sources of income, amount received, and any deductions or credits applicable.

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