Form Na 1256l - Notice Of Action - In-Home Supportive Services (Ihss) Share Of Cost
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1NOTICE OF ACTION
STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF
IN-HOME SUPPORTIVE SERVICES
SOCIAL SERVICES
(IHSS) SHARE OF COST
COUNTY OF
Notice Date:
Case Name:
Case Number:
Here’s how your share of cost for IHSS was determined:
WAS
NOW
Your countable income
$
$
Minus SSI/SSP benefit
$
$
$
$
IHSS Share of Cost
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. Please see the State Hearing Rights insert included with
this notice.
NA 1256L (03/15) IHSS SHARE OF COST
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