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Get CA SR 10 2006-2024

3729-3733 I certify that the information on this form is true and correct. PRINTED NAME OF CPA ADDRESS SR 10 2/06 SIGNATURE OF CPA DATE. CALIFORNIA DEPARTMENT OF SOCIAL SERVICES STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CERTIFICATION OF AUDITED COST DATA The Group Home or Foster Family Agency corporation should have their Certified Public Accountant CPA complete and submit this form as part of the required financial audit if the CPA has not otherwise provided written documentation which clearly shows that the required cost data reports were audited and that the information was fairly stated in all material respects in relation to the basic financial statements taken as a whole. Please have the completed and signed form sent to California Department of Social Services Program and Financial Audits Bureau ATTENTION Financial Audits Unit Manager 744 P Street MS 9-23 Sacramento California 95814. GROUP HOME OR FOSTER FAMILY AGENCY CORPORATE NAME PROGRAM NUMBERS S STREET ADDRESS PROGRAM FISCAL YEAR MO/YR-MO/YR CITY STATE AND ZIP CODE PROVIDER PHONE NUMBER The attached supplementary cost data reports are presented for the purposes of additional analysis and are not a required part of the basic financial statements but are required as supplementary information by the California Department of Social Services in accordance with Manual of Policies and Procedures Section 11-405. 214. Such information has been subjected to the auditing procedures applied in the audit of the basic financial statements and in our opinion is fairly stated in all material respects in relation to the basic fianancial statements taken as a whole. Check only the forms which apply SR 3 SR 4 FCR 12FFA In compliance with the False Claims Act 31 U*S*C. CALIFORNIA DEPARTMENT OF SOCIAL SERVICES STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CERTIFICATION OF AUDITED COST DATA The Group Home or Foster Family Agency corporation should have their Certified Public Accountant CPA complete and submit this form as part of the required financial audit if the CPA has not otherwise provided written documentation which clearly shows that the required cost data reports were audited and that the information was fairly stated in all material respects in relation to the basic financial statements taken as a whole. Please have the completed and signed form sent to California Department of Social Services Program and Financial Audits Bureau ATTENTION Financial Audits Unit Manager 744 P Street MS 9-23 Sacramento California 95814. Please have the completed and signed form sent to California Department of Social Services Program and Financial Audits Bureau ATTENTION Financial Audits Unit Manager 744 P Street MS 9-23 Sacramento California 95814. GROUP HOME OR FOSTER FAMILY AGENCY CORPORATE NAME PROGRAM NUMBERS S STREET ADDRESS PROGRAM FISCAL YEAR MO/YR-MO/YR CITY STATE AND ZIP CODE PROVIDER PHONE NUMBER The attached supplementary cost data reports are presented for the purposes of additional analysis and are not a required part of the basic financial statements but are required as supplementary information by the California Department of Social Services in accordance with Manual of Policies and Procedures Section 11-405. .

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