Form Soc 2269 - In-Home Supportive Services Program Notice To Recipient Cancellation Of Alternate Schedule Due To Recurring Event

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES PROGRAM
NOTICE TO RECIPIENT
CANCELLATION OF ALTERNATE SCHEDULE DUE TO RECURRING EVENT
(ADDRESSEE)
County of:
Notice Date:
Recipient Name:
Recipient Case Number:
IHSS Office Address:
IHSS Office Telephone Number:
To: In-Home Supportive Services (IHSS) Recipient
This notice is to inform you that your request to adjust your maximum weekly hours for
a specified week of each month due to a monthly recurring event has been cancelled.
As of _________________, your provider may not work additional hours during the
CANCELLATION DATE
specified week of each month.
This means that your maximum weekly hours will now be the same for each week of
the month.
If you have any further questions about this notice, you may contact your county IHSS
office at the phone number above.
SOC 2269 (1/16)

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