Form 1255l - Notice Of Action - In-Home Supportive Services (Ihss) Termination
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1
2COUNTY OF
STATE OF CALIFORNIA
NOTICE OF ACTION
HEALTH AND HUMAN
IN-HOME SUPPORTIVE
SERVICES AGENCY
SERVICES (IHSS) TERMINATION
CALIFORNIA DEPARTMENT
(ADDRESSEE)
OF SOCIAL SERVICES
NOTE: This notice relates ONLY to your In-Home Supportive
Services. It does NOT affect your receipt of SSI/SSP, Social
Security, or Medi-Cal. KEEP THIS NOTICE WITH YOUR
IMPORTANT PAPERS.
Notice Date:
Case Name:
Case Number:
Social Worker Name:
Social Worker Number:
Social Worker Telephone:
Social Worker Address:
Your eligibility for the In-Home for Supportive Services will stop as
of _________. Here’s why:
NA 1255L (3/15) IHSS TERMINATION
Case No:
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