Form Soc 310 - Statement Of Facts For In-Home Supportive Services
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4STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATEMENT OF FACTS FOR IN-HOME SUPPORTIVE SERVICES
Note: Your eligibility for In-Home Supportive Services (IHSS), under Welfare and Institutions Code Section 12300, will be
determined by the information you provide on this form.
1.
APPLICANT INFORMATION
FOR COUNTY USE ONLY
NAME (FIRST, MIDDLE, LAST)
BIRTHDATE
CITY
ZIP CODE
HOME ADDRESS
HOME PHONE
MAILING ADDRESS (IF DIFFERENT)
MESSAGE PHONE
(
)
(
)
PLACE OF BIRTH
SOCIAL SECURITY NUMBER
MEDI-CAL CARD NUMBER
ARE YOU:
AGE 65 OR OVER?
DISABLED?
BLIND?
MARITAL STATUS:
MARRIED
SEPARATED
WIDOWED
DIVORCED
SINGLE
(Date
/
/
)
(Date
/
/
)
(Date
/
/
)
(Date
/
/
)
COMPLETE THE FOLLOWING:
NAME OF SPOUSE OR PARENT(S) (IF YOU ARE UNDER 18 YEARS OF AGE)
IS SPOUSE/PARENT(S):
AGE 65 OR OVER?
DISABLED?
BLIND?
SPOUSE/PARENT(S) SOC. SEC. NO.
SPOUSE/PARENT(S) ADDRESS (IF DIFFERENT THAN APPLICANT'S)
DO YOU RESIDE IN CALIFORNIA WITH THE
2.
YES
NO
INTENTION TO CONTINUE RESIDING HERE?
3.
ARE YOU A CITIZEN OF THE UNITED STATES?
(IF “YES”, GO TO “ITEM 4”)
YES
NO
(A.) IF YOU ARE NOT A UNITED STATES CITIZEN, ARE YOU
LAWFULLY ADMITTED TO PERMANENT RESIDENCE OR
YES
NO
LEGALLY PERMITTED TO REMAIN IN THE U S.?
(B.) WHAT IS YOUR ALIEN REGISTRATION NUMBER?
(C.) WHAT IS NAME OF SPONSOR?
(D.) WHAT IS SPONSOR’S ADDRESS?
4.
WHAT IS YOUR LIVING ARRANGEMENT?
ROOM &
TRAILER/
MY HOME IS A:
BOARD
MOTOR HOME
OTHER
HOUSE
APARTMENT
ROOM
LIVE
RECEIVE
OWN/
IN WHICH I:
RENT
COST FREE
BOARD AND CARE
AM BUYING
AMOUNT OF RENT, BOARD AND/OR MORTGAGE PAID
LANDLORD’S NAME
$______________/MONTH
ZIP CODE
ADDRESS
CITY
ARE THERE OTHERS LIVING IN THE HOUSEHOLD?
5.
(IF “YES”, GIVE THE INFORMATION BELOW:)
YES
NO
NAME
RELATIONSHIP
AGE
SOC 310 (1/03)
Page 1 of 4 pages
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