1. CITY/COUNTY AND DEPARTMENT
  2. FEE RATE COLLECTION INFORMATION
  3. Signature
  4. Download Document
  5. metadata

Division of the State Architect | State of California

DISABILITY ACCESS & EDUCATION FEE QUARTERLY REPORT

DGS DSA 786 | Published 8/13/2021

This form is for use by city, county, or city and county representatives for the quarterly reporting of fees collected and transmitted to the Division of the State Architect (DSA) for deposit into the Disability Access and Education Revolving Fund. This form is to accompany the fee transmittal to DSA, which is due within 15 days of the end of each fiscal quarter. Fee collection, transmission and reporting is a requirement under Government Code Section 4467. 

QUARTER DATES

CITY/COUNTY AND DEPARTMENT

$1 FEE RATE COLLECTION INFORMATION

Total Fees Collected

Total Fees Enclosed (30% of Total Fees Collected)

$4 FEE RATE COLLECTION INFORMATION

Total Fees Collected

Total Fees Enclosed (10% of Total Fees Collected)

PREPARER'S INFORMATION

SIGNATURE

Under penalty of perjury, I declare that I have examined this report, and to the best of my knowledge and belief, it is true, correct, and complete.

DOWNLOAD DOCUMENT

Click on the button below to download the completed document. Note that this form is to accompany the fee transmittal to DSA, which is due within 15 days of the end of each fiscal quarter. Fee collection, transmission and reporting is a requirement under Government Code Section 4467.