Form Fc 11 (Audits) - Receipt For Delivery Of Records (Audits)
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1STATE 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
PROGRAM NUMBER
PROVIDER ADDRESS
CITY
STATE
ZIP CODE
Receipt of those records (e.g., books of account, documents, and memoranda) described below from
is hereby acknowledged.
Document Name:
Number of Pages:
Received for Department of Social Services, Foster Care Audits and Rates Branch
BY
TITLE
The return of the above records is hereby acknowledged.
BY
DATE
FC 11 (AUDITS) (10/03)
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