Form Soc 871 - Statement Of Facts (Sof) Summary Sheet In-Home Supportive Services (Ihss) Program Caregiver Background Check Bureau (Cbcb), General Exception Unit (Geu)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATEMENT OF FACTS (SOF) SUMMARY SHEET
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
CAREGIVER BACKGROUND CHECK BUREAU (CBCB), GENERAL EXCEPTION UNIT (GEU)
A.
GENERAL EXCEPTION APPEAL INFORMATION
Legal Case #:
Appeal Request Received:
Acknowledgement Letter Sent:
SOF Due:
County:
County Contact:
B.
GENERAL EXCEPTION APPLICANT PROVIDER INFORMATION
Name (Last, First, MI):
General Exception ID#:
Address:
City:
ZIP Code:
Telephone: (
)
C.
TYPE OF ACTION REQUESTED
■ ■
■ ■
General Exception Denial:
General Exception Rescission:
D.
CBCB GEU INFORMATION
Analyst Name (Last, First):
Telephone: (
)
Mail Station:
Manager Name (Last, First):
Telephone: (
)
Mail Station:
Manager Signature:
Date:
Bureau Chief Signature:
Date:
E.
COMMENTS
PAGE 1 OF 2
SOC 871 (7/12)

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