Form Sr 8 - Financial Audit Report Transmittal
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
FINANCIAL AUDIT REPORT TRANSMITTAL
(Include with Financial Audit Report)
The Group Home (GH),Transitional Housing Placement Plus Foster Care (THP + FC) or Foster Family Agency
(FFA) non-profit corporation should complete and submit this form, a Financial Audit Report for the most
recent fiscal year and audited cost data to continue receiving an AFDC-FC program rate.
Please submit the documents to:
California Department of Social Services
Program and Financial Audits Bureaus
ATTENTION: Financial Audits Unit Manager
744 P Street, MS 8-13-23
Sacramento, California 95814
GROUP HOME OR FOSTER FAMILY AGENCY CORPORATE NAME
NAME OF EXECUTIVE DIRECTOR, ADMINISTRATOR, CEO
FEDERAL EMPLOYERS IDENTIFICATION NUMBER (FEIN)
CORPORATE NUMBER
STATE TAX IDENTIFICATION NUMBER (ffEIN)
PROVIDER PHONE NUMBER
PROVIDER FAX NUMBER
STREET ADDRESS
MAILING ADDRESS
CORPORATION FISCAL YEAR
CITY, STATE, ZIP CODE
CITY, STATE, ZIP CODE
Finanical Audit Report submitted as required. Below are the individual program numbers (e.g., 1234.00.01) for the GH and/or
FFA programs(s) covered by the Financial Audit Report:
_________________, _________________, _________________, _________________, _________________
Federal Expenditures From All Sources
Non-Federal Portion (State,county, etc.)
Items included:
______ Financial Audit Report
______ Audited cost data for each program (SR 3,SR 4, THP + FC, and /or FCR 12FFA) with written documentation
from independent Certified Public Accountant confirming that the cost data were audited. (Covers same
reporting period as Financial Audit Report)
In compliance with the False Claims Act (31 U.S.C. §3729-3733), I certify that all the information on this form
is true and correct.
PRINTED NAME OF EXECUTIVE DIRECTOR OR AUTHORIZED BOARD OFFICER
SIGNATURE OF EXECUTIVE DIRECTOR OR AUTHORIZED BOARD OFFICER
TITLE OF PERSON LISTED ABOVE
DATE
SR 8 (5/15)
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