Form Na 1256 - Notice Of Action - In-Home Supportive Services (Ihss) - Share Of Cost
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1NOTICE OF ACTION
COUNTY OF
STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES (IHSS)
SHARE OF COST
Notice Date:
Case Name:
Case Number:
Here’s how your share of cost for IHSS was determined:
WAS
NOW
Your countable income
$____________
$____________
Minus SSI/SSP benefit
$____________
$____________
IHSS Share of Cost
$____________
$____________
Rules: The rules noted above in parentheses apply; you may review the Manual of Policy and Proce-
dures (MPP) at your local IHSS office.
Questions?: Please contact your IHSS social worker.
State Hearing: If you think this action is wrong, you can ask for a hearing. The back of this page
tells how.
NA 1256 (5/09) IHSS SHARE OF COST (IHSS-R)
Page ____of ____
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