ATTACHMENT II
State of California – Health and Human Services Agency California Department of Social Services
ABATEMENTS NOT PROCESSED THROUGH THE CA 800 CLAIM
CA 800 Reporting period: Month: YR
SECTION A:
COUNTY NAME:
COUNTY CONTACT PERSON:
TELEPHONE NUMBER:
Explanation:
SECTIO
N B:
Abatement Details:
Please submit this form to:
California Department of Social Services
Financial Services Bureau
744 P Street, M.S. 9-5-27
Sacramento, CA 95 814
FAX: (916) 654-1750
I hereby certify, under penalty of perjury, that I am
the official responsible for the administration of the
public welfare programs in said county: that I have
not violated any of the provisions of Sections 1090 to
1096, inclusive, of the Government Code; that the
amounts that the aid payments, aid repayments and
adjustments reflected herein have been made in
accordance with all provisions of the Welfare and
Institutions Code and the rules and regulations of the
California Department of Social Services.
_________________________________________
Signature of County Welfare Director
___________________________________________
Date
I hereby certify, under penalty of perjury, that I am the
officer in aforesaid county responsible for the
examination and settlement of accounts; that I have
not violated any of the provisions of Section 1090 to
1096, inclusive, of the Government Code; that the
amounts claimed herein are in accordance with
authorizations for the above referenced public
assistance programs made by the county; that said
amounts correctly reflect Federal, State and County
shares in the aid payments claimed and that warrants
therefore have issued, according to law and the rules
and regulations of the California Department of Social
Services.
Signature of Cou
nty Auditor-Controller Date
SOC 812B (7/13)