2aa5afcb_anges_to_your_CLIA_Certificate__WHAT_FORM_DO_I_USE_
[I NEED TO:] Request a new Multiple Site CLIA Certificate [ANYTHING ELSE?] If you are applying for Multiple Site exception #2, you must include a copy of your Not-For-Profit Federal 501(c)(3) Tax Determination Letter [WHAT FORM DO I USE?] 
CMS-116 (refer to page 2, Section V – Multiple Sites; you may attach additional pages if you are adding more than two locations)
Illinois CLIA - Making Changes to your CLIA Certificate
WHAT FORM DO I USE?