Fillable Printable Receipt for Delivery of Records - California
Fillable Printable Receipt for Delivery of Records - California
Receipt for Delivery of Records - California
Receipt of those records (e.g., books of account, documents, and memoranda) described below from
is hereby acknowledged.
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCYCALIFORNIA DEPARTMENT OF SOCIAL SERVICES
RECEIPT FOR DELIVERY OF RECORDS (AUDITS)
INSTRUCTIONS:Original to Provider
Copy to Case File
PROGRAM NUMBER
PROVIDER NAMEDATE
PROVIDER ADDRESSCITYSTATEZIP CODE
Document Name:Number of Pages:
Received for Department of Social Services, Foster Care Audits and Rates Branch
The return of the above records is hereby acknowledged.
BY
BY
TITLE
DATE
FC 11 (AUDITS) (10/03)
