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 AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
RECEIPT FOR DELIVERY OF RECORDS (AUDITS)
INSTRUCTIONS: Original to Provider
Copy to Case File
PROVIDER NAME DATE
PROVIDER ADDRESS CITY STATE ZIP 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.
FC 11 (AUDITS) (10/03)