Acknowledgement Sample Forms: I. Form for Ordinary Certificate of Acknowledgment. Complete the Release of Health Information form, next have your former physician complete the request.Thank you for you interest in the University of Texas Health Science Center at Houston. Sincerely,. Name. Title. Enclosure. Check out our cash acknowledgement template selection for the very best in unique or custom, handmade pieces from our templates shops. The sample acknowledgement letters for receipt of payment provided below can be used as format templates for official and personal purposes. A good donor acknowledgment letter is both a transaction record and a donor engagement opportunity. Here's how to write one. To register for a licensed account complete the iPermits Acknowledgement form. Non-licensed user may complete their account set up online.