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For Assisted Living providers that have been waiting for more than 5 weeks for their tax ID number to be validated, or have not received their payment from the Phase 2 Provider Relief Fund, please enter your information below so we can send to Federal Health and Human Services for resolution.

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* 1. Assisted Living Facility Name

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* 2. ALF Licensure #

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* 3. Facility Address

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* 4. Facility City

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* 5. Facility State

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* 6. Facility Zip Code

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* 7. Facility Tax ID Number

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* 8. Taxpayer ID Number (only if different from facility)

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* 9. Taxpayer Address (only if different from facility) 

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* 10. Taxpayer City (only if different from facility) 

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* 11. Taxpayer ST (only if different from facility) 

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* 12. Taxpayer Zip Code (only if different from facility) 

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* 13. Contact First Name

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* 14. Contact Last Name

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* 15. Contact Title

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* 16. Company Name

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* 17. Phone Number

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* 18. Email

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