Fillable RELEASE FORM NOTICE: This is a legally binding (California)

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RELEASE FORM NOTICE: This is a legally binding (California)

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________________________________________________________________________________
________________________________________________________________________________
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
RELEASE FORM
NOTICE: This is a legally binding document. Consult your attorney if you do not understand any part
of it.
THIS RELEASE is made on the
____________________
day of
__________________,
20
______,
by
(PRINT NAME)
whose residence and/or mailing address is
(PRINT ADDRESS)
______________________
I understand that I owe no debt to the Food and Nutrition Service (FNS), and I relinquish all rights to
donated funds in the amount of dollars
($______________),
tendered to
FNS on this date. I understand such funds are a donation to and made payable to FNS, and that the
donation to FNS is not returnable. I agree that the funds are donated with no expectation of
something in return from any federal, state, or local government entity.
SIGNATURE: DATE:
CF 21 (3/14)
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Completed 30 March 2022

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