Form Soc 865 - In-Home Supportive Services (Ihss) Request For Applicant Provider Reference
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2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES (IHSS)
REQUEST FOR APPLICANT PROVIDER REFERENCE
Applicant Provider: You must enter your full name in the space below and at the top of the next page BEFORE
you give this form to your reference for completion.
REFERENCE REQUEST FOR: _______________________________________
Person Submitting Reference: In-Home Supportive Services (IHSS) providers are caregivers for elderly, blind,
and/or disabled individuals in their own homes. The above-named person has requested to be an IHSS provider
but he/she was found ineligible due to a felony criminal conviction(s). He/she is requesting a general exception,
which, if granted, would allow him/her to be an IHSS provider despite his/her felony criminal conviction(s). The
information you provide will help us evaluate whether this person should be granted a general exception and
allowed to be an IHSS provider.
Please complete the information below.
Your Name:
Date Completed:
Street Address:
City:
State:
ZIP Code:
Daytime Telephone Number:
(
)
Please answer all questions on this form to the best of your ability.
1.
How long have you known the person you are writing this reference for?
______________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
2.
How do you know this person?
_________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
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SOC 865 (7/12)
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