Form Soc 450 - Voluntary Services Certification
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
VOLUNTARY SERVICES CERTIFICATION
(PLEASE TYPE OR PRINT CLEARLY)
RECIPIENT NAME
RECIPIENT CASE NUMBER
COUNTY
PROVIDER NAME
PROVIDER TELEPHONE NUMBER
PROVIDER SOCIAL SECURITY NUMBER
*
(OPTIONAL)
PROVIDER STREET ADDRESS
CITY
ZIP CODE
DAYS AND/OR HOURS PER MONTH SERVICES
SERVICES TO BE PROVIDED
ARE TO BE PROVIDED
I agree to provide the above listed services voluntarily. I know that I have the right to be compensated but choose not
to accept any payment, or reduced payment for the provision of these services
PROVIDER SIGNATURE
DATE
SOCIAL SERVICE WORKER SIGNATURE
DATE
*
FOR IDENTIFICATION PURPOSES ONLY (AUTHORITY: WELFARE & INSTITUTIONS CODE SECTION 12302.2)
SOC 450 (4/99)
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