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Fillable Form Sr 4 Group Home Program Payroll & Fringe
__________________________________________________________
Contact Person: _______________________ Telephone Number: (
) __________________
PLEASE USE CURRENT DATA TO RESPOND TO THIS SURVEY
1. ___
Enter the number of facilities currently licensed and pending licensure under your
corporate name for this group home program.
2. ___
Enter the number of facilities owned by the corporation for which the corporation
has clear title or has a mortgage/deed of trust.
3. ___
Enter the number of...
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