Form Ihss-E 003 - In-Home Supportive Services (Ihss) Program - Notice To Recipient For Discontinuance Of Exemption From Workweek Limitations For Extraordinary Circumstances

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
NOTICE TO RECIPIENT FOR DISCONTINUANCE OF EXEMPTION FROM
WORKWEEK LIMITATIONS FOR EXTRAORDINARY CIRCUMSTANCES
(ADDRESSEE)
COUNTY OF:
Notice Date:
IHSS Office Address:
IHSS Office Telephone:
Recipient Name:
Case Number:
Provider Name:
Provider Number:
To: In-Home Supportive Services (IHSS) Recipient
This notice is to inform you that at the end of service month _________________, the
Month and Year
Exemption From Workweek Limitations for Extraordinary Circumstances (Exemption 2)
will be discontinued for your IHSS provider listed above because:
Your provider is no longer providing services for one or more of the recipients
for which the exemption was granted.
Your provider no longer resides with one or more of the recipients for which the
exemption was granted.
One or more of the recipients for which the exemption was granted has had a
reduction in authorized IHSS hours, which allows your provider to work within
the workweek limitations.
One or more of the recipients for which the exemption was granted no longer
meets the criteria for an Exemption 2.
The recipient(s) have hired an additional provider(s) and therefore, your
provider is able to comply with the workweek limitations
OTHER: _______________________________________________________
_______________________________________________________________
_______________________________________________________________
IHSS-E 003 (1/17)
PAGE 1 OF 2

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