Assisted Living Facility Missing Provider Relief Fund Survey

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.
1.Assisted Living Facility Name
2.ALF Licensure #
3.Facility Address
4.Facility City
5.Facility State
6.Facility Zip Code
7.Facility Tax ID Number
8.Taxpayer ID Number (only if different from facility)
9.Taxpayer Address (only if different from facility) 
10.Taxpayer City (only if different from facility) 
11.Taxpayer ST (only if different from facility) 
12.Taxpayer Zip Code (only if different from facility) 
13.Contact First Name
14.Contact Last Name
15.Contact Title
16.Company Name
17.Phone Number
18.Email
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