In-Home Supportive Services (Ihss) Program. Live-In Family Care Provider Overtime Exemption - California Page 3

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Provider Number__________________________
I declare that I meet all of the requirements to qualify for this exemption. I further declare that all of the
information I have provided on this form is true and correct to the best of my knowledge. I understand that
verification of this information will occur at the time of my IHSS recipient’s reassessment to determine if I
still qualify for this exemption. I agree to adhere to all requirements for overtime under this exemption. If I
no longer meet the three (3) requirements for this exemption I will no longer qualify for this exemption and I
must notify the county immediately. I understand that I will then be subject to the existing overtime limitation
restrictions.
PROVIDER SIGNATURE:
DATE:
PROVIDER’S PRINTED NAME:
FOR STATE USE ONLY
STAFF NAME:
DATE:
NOTES:
SOC 2279 (1/16)
PAGE 3 OF 3

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