California > Workers Comp > General
Declaration Of Custodian Of Records - California
|Declaration Of Custodian Of Records Form. This is a California form and can be used in General Workers Comp .||
|Get this form for FREE as a print-only pdf|
DECLARATION OF CUSTODIAN OF RECORDS I HEREBY DECLARE, under penalty of perjury, that the following statements are true to the best of my knowledge and belief. I am the duly authorized custodian of records of the below named and certify that the accompanying records are true and complete copies of records maintained in the regular course and scope of business of my employer and were prepared by authorized personnel at or near the time of the acts, conditions or events which they intend to convey. No documents, records or other materials have been withheld except as noted below. Certain records were omitted because: OR, IN THE ALTERNATIVE I HEREBY DECLARE, under penalty of perjury, that I have NO RECORDS on the patient, employee, or subject in request. Please explain if you have no records: Records Subpoenaed From: Re: on , Signature of Custodian File Number W.C.A.B. No. Case Number 2002 © American LegalNet, Inc.