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Payment to Agency Report A Public Document PAYMENT TO AGENCY REPORT 1. Agency Name Date Stamp California Department of Health Care Services 801 For Official Use Only Division, Department, or Region

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Step 1: Download the dhcs-fppc-801-1-30-17-2pdf form from the official website.

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Step 2: Fill out your personal information, including your name, address, and contact details at the top of the form.

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Step 3: Provide the name of the agency you are making the payment to, along with their address and contact information.

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Step 4: Enter the payment amount in the designated field, ensuring it matches the amount you are supposed to pay.

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Step 7: Make a copy of the completed form for your records before submitting it to the agency.

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DHCS-FPPC-801-1-30-17-2pdf payment to agency is a form used for reporting payments made to agencies.

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Any individual or entity that has made payments to agencies is required to file DHCS-FPPC-801-1-30-17-2pdf payment to agency.

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To fill out DHCS-FPPC-801-1-30-17-2pdf payment to agency, you need to provide details of the payments made to agencies during the reporting period.

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The purpose of DHCS-FPPC-801-1-30-17-2pdf payment to agency is to ensure transparency and accountability in financial transactions with agencies.

What information must be reported on dhcs-fppc-801-1-30-17-2pdf payment to agency?

The information that must be reported on DHCS-FPPC-801-1-30-17-2pdf payment to agency includes the name of the agency, date of payment, amount of payment, and purpose of payment.

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