Form Soc 863 - In-Home Supportive Services (Ihss) Applicant Provider Request For General Exception Page 2

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IN-HOME SUPPORTIVE SERVICES (IHSS)
APPLICANT PROVIDER REQUEST FOR GENERAL EXCEPTION
Based on the CBCB factors A through H listed on the previous page, applicant providers must
enclose all of the following with this form:
1. A copy of the denial notice (SOC 852A) stating your ineligibility to be an IHSS provider.
2. A copy of form SOC 426 (IHSS Program Provider Enrollment Form), which you previously
completed and submitted to the county.
3. Documentation (Minute Order, Court-Issued Judgment of Conviction, or a letter from the
Probation Department) showing that your current or last probation period was informal,
if applicable.
4. A description of, and verification if available of, any completed training, classes, treatment,
counseling, or community service activities that would indicate rehabilitation or changed
behavior. Provide verification of completion (for example, certificates or diplomas), if applicable.
5. Evidence of an official pardon by the Governor, if applicable.
6. Employment history for the last 10 years.
7. Copies of all police reports involving the disqualifying crime(s) for which you were convicted
or a letter from law enforcement stating that a report no longer exists.
8. Three (3) signed character reference statements that include the following information:
a. How long the person has known you
b. How the person knows you (this could be a description of how this person came to know
you)
c. A statement of the person’s opinion of your character
d. A description of any interaction between you and a person who is elderly, blind, or disabled
who you have assisted
e. Other comments that would help describe your desire to work as an IHSS provider
The reference statements must be obtained and dated after the date of your denial notice. They
may be completed by current or former employers or other persons you choose. You are limited
to one reference from a family member.
9. A signed personal statement including the following information:
A. A description of the events surrounding the disqualifying crime(s) for which you were
convicted, including what happened, why it happened, how it happened, description of the
victim (if known, gender, approximate age, physical characteristics, relationship to victim),
and other relevant information about the disqualifying crime(s) or any other conviction(s).
The CBCB may compare your statement with police reports and court documents.
SOC 863 (1/11)
PAGE 2 OF 3

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