In-Home Supportive Services (Ihss) Program And Waiver Personal Care Services (Wpcs) Program Live-In Self-Certification Cancellation Form For Federal And State Tax Wage Exclusion

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM AND
WAIVER PERSONAL CARE SERVICES (WPCS) PROGRAM
LIVE-IN SELF-CERTIFICATION CANCELLATION FORM FOR
FEDERAL AND STATE TAX WAGE EXCLUSION
Provider Name
Recipient Name
Provider Number
Recipient Case Number
County Of Residence
ALL INFORMATION ON FORM MUST BE PRESENT TO CANCEL EXCLUSION.
SEE BACK OF FORM FOR INSTRUCTIONS.
I no longer live with my Recipient __________________________, and would like to
remove the existing Self-Certification for the exclusion of my IHSS/WPCS wages from
federal and state personal income taxes.
Provider Signature:
Date of Signature:
RETURN COMPLETED FORM TO:
IHSS – IRS Live-In Self-Certification
P.O. Box 272854
Chico, CA 95927-2854
PAGE 1 OF 2
SOC 2299 (12/16)

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