Form Sr 10 - Certification Of Audited Cost Data
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1CALIFORNIA 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 8-13-23
Sacramento, California 95814.
GROUP HOME OR FOSTER FAMILY AGENCY CORPORATE NAME
PROGRAM NUMBERS(S)
STREET ADDRESS
PROGRAM FISCAL YEAR (MO/YR-MO/YR)
PROVIDER PHONE NUMBER
CITY, STATE, AND ZIP CODE
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___ THP + FC ___
In compliance with the False Claims Act (31 U.S.C. §3729-3733), I certify that the information on this
form is true and correct.
PRINTED NAME OF CPA
SIGNATURE OF CPA
DATE
ADDRESS
CITY, STATE AND ZIP CODE
SR 10 (5/15)
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