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Get the free printed: 06/21/2023 - form approved omb no. 0938-0391

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PRINTED: 06/16/2023 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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Printed 0621 - form is a tax form used for reporting certain types of income or payments.
Individuals or businesses who have received income or made payments that are required to be reported on printed 0621 - form.
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Printed 0621 - form requires information such as income amount, payer or payee details, and any relevant tax withholding information.
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