State of California — Health and Human Services Agency
Department of Health Care Services
DHCS 2352 (7/07)
Instructions to Contractor:
With final invoice(s) submit one (1) original and one (1) copy. The original must bear the original signature of a person
authorized to bind the Contractor. The additional copy may bear photocopied signatures.
Submission of Final Invoice
Pursuant to contract number
entered into between the Department of Health Care Services (DHCS)
and the Contractor (identified below), the Contractor does acknowledge that final payment has been requested via invoice
, in the amount(s) of $
If necessary, enter "See Attached" in the appropriate blocks and attach a list of invoice numbers, dollar amounts and invoice dates.
Release of all Obligations
By signing this form, and upon receipt of the amount specified in the invoice number(s) referenced above, the Contractor does
hereby release and discharge the State, its officers, agents and employees of and from any and all liabilities, obligations, claims, and
demands whatsoever arising from the above referenced contract.
Repayments Due to Audit Exceptions / Record Retention
By signing this form, Contractor acknowledges that expenses authorized for reimbursement does not guarantee final allowability of
said expenses. Contractor agrees that the amount of any sustained audit exceptions resulting from any subsequent audit made
after final payment will be refunded to the State.
All expense and accounting records related to the above referenced contract must be maintained for audit purposes for no less than
three years beyond the date of final payment, unless a longer term is stated in said contract.
Recycled Product Use Certification
By signing this form, Contractor certifies under penalty of perjury that a minimum of 0% unless otherwise specified in writing of post
consumer material, as defined in the Public Contract Code Section 12200, in prod