1st Line – Name
2nd Line – Address
3rd Line – City, State and ZIP Code

Item 33 identifies the provider that is requesting to be paid for the services rendered and should always
be completed. Do not use punctuation (i.e., commas, periods) or other symbols in the address (e.g., 123 N Main Street
101 instead of 123 N. Main Street, #101). Enter a space between town name and state code; do not
include a comma. Report a 9-digit ZIP code. Enter the data that will fit.