Form Na 1257 - Notice Of Action In-Home Supportive Services (Ihss) Multi

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NOTICE OF ACTION
COUNTY OF
STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES (IHSS)
Notice Date :
Case Name :
Case Number :
NOTE: This notice relates ONLY to your In-Home Supportive
Social Worker Name :
Services. It does NOT affect your receipt of SSI/SSP, Social
Security, or Medi-Cal.
KEEP THIS NOTICE WITH YOUR
Social Worker Number :
Social Worker Telephone :
IMPORTANT PAPERS.
Social Worker Address :
(ADDRESSEE)
You must immediately tell the county about any changes that might affect your eligibility or need
for IHSS, including any changes in income, property, living arrangements, medical conditions or
the ability to work. If you have any questions or think more facts should be considered, call your
social worker.
Rules: The rules noted above in parentheses apply; you may review the Manual of Policy and Procedures
(MPP) at your local IHSS office.
Questions?: Please contact your IHSS social worker.
State Hearing: If you think this action is wrong, you can ask for a hearing. The back of this page tells how.
NA 1257 (5/09) - IHSS MULTI
Page 1 of ____

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