In-Home Supportive Services (Ihss) Program. Live-In Family Care Provider Overtime Exemption - California Page 2

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Provider Number__________________________
Part B: PROVIDER & RECIPIENTS’ INFORMATION
INSTRUCTIONS: You must complete the information below about your residential and mailing addresses and then
complete the chart below for the recipients you provide services to.
1.Your residential address: _____________________________________________________________________
_________________________________________________________________________________________
2.Your mailing address: _______________________________________________________________________
__________________________________________________________________________________________
A
B
C
Recipient Information
Relationship to Recipient Does this recipient live with
you in the same residence?
Name
Case Number
Please answer Yes or No
1.
1.
1.
2.
2.
2.
3.
3.
3.
4.
4.
4.
SOC 2279 (1/16)
PAGE 2 OF 3

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