ATTACHMENT I
State of California – Health and Human Services Agency
California Department of Social Services
ABATEMENTS NOT PROCESSED THROUGH THE COUNTY EXPENSE CLAIM
CEC Reporting Period: Quarter:
YR
SECTION A:
COUNTY NAME:
COUNTY CONTACT PERSON:
TELEPHONE NUMBER:
Explanation:
SECTION B:
Abatement Details:
Program
Program
Amounts ($)
Name
Identifier Number
(PIN) Code
Federal
State/County
Health
County
Total
2011
Please submit this form to:
California Department of Social Services
Financial Services Bureau
744 P Street, M.S. 9-5-27
Sacramento, CA 95814
FAX: (916) 654-1750
I hereby certify, under penalty of perjury, that I am
I hereby certify , under penalty of perjury, that I am the
the official responsible for the examination and
official responsible for the examination and settlement of
settlement of accounts; that I have not violated any of
accounts; that I have not violated any of the provisions of
the provisions of Code of Federal Regulations, 7
Code of Federal Regulations, 7 CFR Part 3018 and 45
CFR Part 3018 and 45 CFR Part 93, regarding
CFR Part 93, regarding lobbying restrictions, and
lobbying restrictions, and sections 1090 and 1906,
Sections 1090 and 1906. Inclusive of the Government
inclusive of the Government Code; that the
Code; that the amount(s) reported herein has been
amount(s) reported herein has been paid and is
authorized by the welfare director; and that warrants
properly chargeable as an expenditure or credit to
therefore have been issued or expenditures/credits
administration of welfare programs in accordance
otherwise incurred according to law.
with all provisions of the Welfare and Institutions
Code and rules and regulations of the California
Department of Social Services.
__________________________________________
______________________________________________
Signature of County Welfare Director
Date
Signature of County Auditor-Controller
Date
SOC 812A (7/13)