Form SOC 450 at a glance
What it is: SOC 450 is the Voluntary Services Certification of the California Department of Social Services.
Who signs: The provider signs on the Provider Signature line and the Social Service Worker signs on the Social Service Worker Signature line, and each enters the Date.
A filled-in Form SOC 450 example: a volunteer provider lists two services
How to fill out Form SOC 450, box by box
Recipient name, case number and county
Enter the Recipient Name, Recipient Case Number and County.
Provider name, telephone number and Social Security Number
Enter the Provider Name, Provider Telephone Number and Provider Social Security Number, which is optional.
The Provider Social Security Number (Optional)* is for identification purposes only (Authority: Welfare & Institutions Code Section 12302.2).
Provider street address, city and zip code
Enter the Provider Street Address, City and Zip Code.
Services to be provided and days and/or hours per month
List the Services To Be Provided and the Days and/or Hours per month the services are to be provided.
More rules for Form SOC 450
Please type or print clearly.
The provider agrees to provide the services listed under Services To Be Provided voluntarily, knows of the right to be compensated, and chooses not to accept any payment, or reduced payment, for the provision of these services.
Common questions about Form SOC 450
Who signs it?
The provider signs on the Provider Signature line and enters the Date. The Social Service Worker signs on the Social Service Worker Signature line and enters the Date.
Sources
[1] Form SOC 450 (4/99), Voluntary Services Certification, California Department of Social Services (the Official source link on this page).