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Click ‘Get Form’ to open the Revised 07/00 in the editor.
Begin by filling in your name and address in the designated fields at the top of the form. Ensure that all information is accurate to avoid any issues.
In the declaration section, clearly state your acknowledgment of the truthfulness of your declaration. This is crucial as it affirms your understanding of the penalties for false declarations.
Sign the document where indicated under 'Signature Of Person Making Declaration'. Make sure your signature is clear and legible.
Fill in the location and date of declaration. This includes specifying where you are declaring and the exact date on which you are signing.
Finally, have a witness sign in the appropriate section. The witness must print their name, provide their address, and indicate their status (e.g., Justice of the Peace).

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Versions	Form popularity	Fillable & printable
2011	4.8 Satisfied (155 Votes)
2010	4.3 Satisfied (67 Votes)
2000	4.3 Satisfied (48 Votes)
1995	4.3 Satisfied (24 Votes)

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What are CCS eligible conditions?

Examples of eligible conditions include diseases of the pituitary, thyroid, parathyroid, thymus, adrenal, pancreas, ovaries and ; growth hormone deficiency, diabetes mellitus, diseases due to congenital or acquired immunologic deficiency manifested by life-threatening infections, inborn errors of metabolism;

What is CCS for?

A SAR, or Service Authorization Request, is an authorization from CCS to allow medical providers to bill for services related to your childs CCS-eligible condition.

Why did I get a letter from CCS?

Debt collection agencies like CCS Collect may contact you if you owe money to a creditor and the creditor has sold the debt to the agency. Once CCS Collect buy debt from the original creditor, they will take it upon themselves to attempt to recover the money owed.

What is a ccs numbered letter?

CCS Numbered Letters are the documents sent to county CCS programs that provide policy guidance for administration of the program. Current and archived Numbered Letters can be found at the State CCS website. You can search the site by topic to find Letters addressing a specific issue.