Notice and Acknowledgment of Receipt-Civil. Notice and Acknowledgment of Receipt. (form. FL-117.) and a postage-paid return envelope addressed to me. Contra Costa County. Complete and sign the sworn statement in item 4 in front of the notary public. Request the notary acknowledge your signature in the sworn statement in item 4. Fill out a a Media Design Department Materials and Services Receipt. The addenda must be signed and attached to the final response. Acknowledgement of Receipt of the Written Policies. 30. Participation Handbook Acknowledgment of Receipt (attached).