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The amount on yotch the Total Amount Transmitted. 7. Sign and date the form. 8. Mail the top copy of the form and your check to address on the front of the form. 9. Mail one copy to the CSO. 10. File a copy in your files     $ `$ DSHS 01-210 (09/2002) p?CES_AU7AmountRetur0ir###000#,##0.00 // #####;#####-####(###) ###-####@@X  ^v  @@@@@@ @@@@@Aj|jc{ cjcjc{ <c,A<{ c ptlcaA < A ccA@A cA>>JA*> MJv^ *Q9P<v^ QK<F@@@ @@X  " @@@  @@X   @@@   @@X   @@c!_"<&@@X 2 HNTX   @@c!_"<&@@VWX a] HN^]T]wpm,pB @ 6TRANSMITTAL OF CLIENT FUNDS FROM THE PROTECTIVE PAYEE  G G J G,Arial (+ TRANSMITTAL OF (9&CLIENT FUNDS FROM THE PROTECTIVE PAYEEP!p/H'  d`!p' Transmittal Number:  [ ` TO:     EDSHS OFFICE OF ACCOUNTING SERVICES PO BOX 9501 OLYMPIA WA 98507-9501  C" "C G C",Arial (U,DSHS (a,OFFICE OF ACCOUNTING SERVICES (m, PO BOX 9501 (y,OLYMPIA WA 98507-9501@0%@ eP@% PROTECTIVE PAYEE NAME\@%/@ fP% / !TELEPHONE NUMBER (WITH AREA CODE)0@/@P g@Q/ ADDRESS"@0!P@ hP@!@ CITY@!P%@ iP!`% STATE@%/@ jP% / ZIP CODE!` /C ` @  k p  1. @  @ l A CITY   0@  @ m @ A CITY  0 0@  @ n  A` CITY  0 @  @ o  A!@ CITY   ` %@  @ p " A' CITY  @ TO   0 % % /@ @ q ' A/ CITY  ` @   p  2. @ @  A CITY  0@ @  @ A CITY  00@ @   A` CITY  0@ @   A!@ CITY   `%@ @  " A' CITY  @ TO   0% %/@ @  ' A/ CITY ` @ p 3. @ @  A CITY 0@ @  @ A CITY 00@ @   A` CITY 0@ @   A!@ CITY  `%@ @  " A' CITY @ TO  0%%/@ @  ' A/ CITY ` @ p 4. @ @  A CITY 0@ @  @ A CITY 00@  @   A` CITY 0@! @   A!@ CITY  `%@" @  " A' CITY @ TO  0%%/@# @  ' A/ CITY ` @$ p 5. @% @  A CITY 0@& @  @ A CITY 00@' @   A` CITY 0@( @   A!@ CITY  `%@) @  " A' CITY @ TO  0%%/@* @  ' A/ CITY ` @+ p 6. @, @  A CITY 0@- @  @ A CITY 00@. @   A` CITY 0@/ @   A!@ CITY  `%@0 @  " A' CITY @ TO  0%%/@1 @  ' A/ CITY ` @2 p 7. @3 @  A CITY 0@4 @  @ A CITY 00@5 @   A` CITY 0@6 @   A!@ CITY  `%@7 @  " A' CITY @ TO  0%%/@8 @  ' A/ CITY ` @9 p 8. @: @  A CITY 0@; @  @ A CITY 00@< @   A` CITY 0@= @   A!@ CITY  `%@> @  " A' CITY @ TO  0%%/@? @  ' A/ CITY ` @@ p 9. @A @  A CITY 0@B @  @ A CITY 00@C @   A` CITY 0@D @   A!@ CITY  `%@E @  " A' CITY @ TO  0%%/@F @  ' A/ CITY ` @G p 10.  @H @  A CITY 0@I @  @ A CITY 00@J @   A` CITY 0@K @   A!@ CITY  `%@L @  " A' CITY @ TO  0%%/@M @  ' A/ CITY     CLIENT NAME/ 0@  %AMOUNT OF CLIENT FUNDS BEING RETURNEDZ Z J Z,Arial (hAMOUNT OF CLIENT (r FUNDS BEING (wRETURNED 0 0 `    0 0 % % / 0( -0 ENTER REASON CODEM %@ *@ $1. LOSS OF CONTACT 2. DSHS REQUESTJ J Z J,Arial (T1. LOSS OF CONTACT (T2. DSHS REQUEST *@ . $3. INCARCERATED 4. OTHER (EXPLAIN)  J ,Arial (3. INCARCERATED (4. OTHER (EXPLAIN) 0  !ACES CLIENT IDENTIFICATION NUMBER   ,Arial ( ACES CLIENT (IDENTIFICATION (NUMBER `  ACES AU NUMBER? ` " PERIOD OF TIME9  ` FROM "0 `# TO  "@ p :I certify that the inforamtion is correct and check number  . . J .,Arial (.I certify that the inforamtion is correct and (  check number!"0 HN0 # $! Transmittal Number:  [ ! "@ !for the total amount is attached.     )p"@/@O!  )!/ DATE P! PROTECTIVE PAYEE'S SIGNATUREw 0"@)p `"@0"@`$@P" "Pp" RECEIVED BY: NAMEI"@$0@Q" "P"  DATE RECEIVED8"0#.0HR "@# CRJ and Line Number:  f "@0$/` 0C0 @0 TOTAL AMOUNT TRANSMITTED    0 0 @S @   A` CITY 0 /C$ `$ 0 "DSHS 01-210 (09/2002) (AC 07/2009) $@@$)` H*COPIES TO: Office of Accounting Services; CSO; Protective Payee's Files  P001OPOSED FORM - DO NOT PRINT MILLIE$@@$0 i*DISTRIBUTION: White - Office of Accounting Services Pink - CSO Yellow - Protective Payee's Files  < SmO'oGlFf>n X  U 0 x   P k:Z2zG:oh@`gh%e fi,j4qz R*r+prJ"jdf TransmittalPPNamePPPhone PPAddressPPCityPPStatePPZip ClientName1ACES_ID1ACES_AU1AmountReturned1 FromDate1ToDate1Reason1 ClientName2ACES_ID2ACES_AU2AmountReturned2 FromDate2ToDate2Reason2 ClientName3ACES_ID3ACES_AU3AmountReturned3 FromDate3ToDate3Reason3 ClientName4ACES_ID4ACES_AU4AmountReturned4 FromDate4ToDate4Reason4 ClientName5ACES_ID5ACES_AU5AmountReturned5 FromDate5ToDate5Reason5 ClientName6ACES_ID6ACES_AU6AmountReturned6 FromDate6ToDate6Reason6 ClientName7ACES_ID7ACES_AU7AmountReturned7 FromDate7ToDate7Reason7 ClientName8ACES_ID8ACES_AU8AmountReturned8 FromDate8ToDate8Reason8 ClientName9ACES_ID9ACES_AU9AmountReturned9 FromDate9ToDate9Reason9 ClientName10 ACES_ID10 ACES_AU10AmountReturned10 FromDate10ToDate10Reason10 CheckNumber SignatureDateReceivedByName DateReceived CRJLineNumberAmountReturned11   0@  @ I, * How to Complete and Use TRANSMITTAL OF CLIENT FUNDS FROM THE PROTECTIVE PAYEE, DSHS 01-210 1. Use one form per CSO. 2. Transmittal number is for your use in tracking individual transactions. 3. Complete the Agency/company/your name and address. 4. Use one line for each client that you are returning funds for. 5. Complete each column. Period of time is the months of grant received being returned. Enter the number code for why the money is being returned. If 4 is selected then explain the reason for the return. The total amount transmitted is the total of all the client's money being returned. 6. In the space after check number enter the number of your check. The amount on your check should match the Total Amount Transmitted. 7. Sign and date the form. 8. Mail the top copy of the form and your check to address on the front of the form. 9. Mail one copy to the CSO. 10. File a copy in your files     $ `$ !DSHS 01-210 (09/2002) (AC07/2009) P002 p  2.N  T`VWX  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVXƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzrƌzri TransmittalPPNamePPPhone PPAddressPPCityPPStatePPZip ClientName1ACES_ID1ACES_AU1AmountReturned1 FromDate1ToDate1Reason1 ClientName2ACES_ID2ACES_AU2AmountReturned2 FromDate2ToDate2Reason2 ClientName3ACES_ID3ACES_AU3AmountReturned3 FromDate3ToDate3Reason3 ClientName4ACES_ID4ACES_AU4AmountReturned4 FromDate4ToDate4Reason4 ClientName5ACES_ID5ACES_AU5AmountReturned5 FromDate5ToDate5Reason5 ClientName6ACES_ID6ACES_AU6AmountReturned6 FromDate6ToDate6Reason6 ClientName7ACES_ID7ACES_AU7AmountReturned7 FromDate7ToDate7Reason7 ClientName8ACES_ID8ACES_AU8AmountReturned8 FromDate8ToDate8Reason8 ClientName9ACES_ID9ACES_AU9AmountReturned9 FromDate9ToDate9Reason9 ClientName10 ACES_ID10 ACES_AU10AmountReturned10 FromDate10ToDate10Reason10 CheckNumber SignatureDateReceivedByName DateReceived CRJLineNumberAmountReturned11