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NEW YORKSTATEDEPARTMENTOF HEALTH DIVISION HEALTHPLANCONTRACTINGANDOVERSIGHT ARTICLES 44 AND 49 STATEMENT DEFICIENCIESNAME OF MANAGED CARE ORGANIZATION Affinity Health Plan, Inc. STREET ADDRESS, CITY,

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To fill out a New York DID NOT form, follow these steps: 1. Obtain a copy of the New York DID NOT form from the official website or local government office. 2. Read the instructions carefully before filling out the form. 3. Provide your personal information, such as your name, address, and contact details. 4. Clearly state the reason why you did not do something that was required. 5. Attach any supporting documents or evidence, if necessary. 6. Review the completed form for accuracy and make any necessary corrections. 7. Sign and date the form. 8. Submit the filled-out form to the appropriate authority as instructed.

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New York Did Not is a form that individuals or businesses may need to file if they did not conduct business in New York during the tax year.

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