Form Dhcs 4000 A - California Genetically Handicapped Persons Program (Ghpp) Application To Determine Eligibility - Health And Human Services Agency Page 10

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State of California – Health and Human Services Agency
California Department of Health Care Services
Genetically Handicapped Persons Program (GHPP)
INSTRUCTIONS FOR COMPLETING
THE GENETICALLY HANDICAPPED PERSONS PROGRAM (GHPP)
INITIAL/ANNUAL INCOME VERIFICATION FORM
Section C: Enrollment Fee Information: Read this important information about your enrollment fee.
Section D: Certification: Read and initial the statements where indicated on the form. Then sign and date in ink in the spaces
provided. If you sign your name with an “X,” you must have a witness sign in the space indicated.
Submitting your application: Mail the completed form to the GHPP at: Genetically Handicapped Persons Program, MS 8100, P.O.
Box 997413, Sacramento, CA 95899-7413.
1) Civil Code, Section 1798.17
2) In accordance with Section 41670, Title 22, California Code of Regulations and the California Public Records Act (Government Code, Sections
6250-6255)
3) Section 123800 et. seq. of the California Health and Safety Code
DHCS 4000 B (2/08)
Page 4 of 4

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