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 Page 2

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Instructions for filling out the Live-In Self-Certification
Cancellation Form
1. All requested information must be entered on the form in the designated area.
2. You must sign and date the form on the designated line.
3. Only use black ink and please print clearly.
4. Do not wrinkle or staple the form.
5. Provider Name: Enter your name as it appears on your IHSS paperwork.
6. Provider Number: May be found on your IHSS paperwork – Provider Notification of
Recipient Authorized Hours and Services and Maximum Weekly Hours, Provider
Timesheet, etc.
7. Recipient Case Number: May be found on your IHSS paperwork – Provider
Notification of Recipient Authorized Hours and Services and Maximum Weekly
Hours, Provider Timesheet, etc.
8. Recipient County of Residence: Please enter the county where you and your
Recipient reside.
PAGE 2 OF 2
SOC 2299 (12/16)

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