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IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM …

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READ THE INFORMATION BELOW CAREFULLY BEFOREYOU BEGIN TO COMPLETE THIS FORMUnder state law, if you have been convicted of or incarcerated following a conviction forcertain exclusionary crimes within the past 10 years, you are not eligible to be enrolledas a provider or to receive payment from the IHSS PROGRAM for providing supportiveservices except as specified below. There are two categories of exclusionary crimes. Tier 1 crimes, as set forth in Welfare and Institutions Code (W&IC) , include the following:1. Specified abuse of a child (Penal Code [PC] section 273a[a]*),2. Abuse of an elder or dependent adult (PC section 368*), and3.

IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM PROVIDER ENROLLMENT FORM INSTRUCTIONS: • Use black or blue ink to fill out. Print information clearly.

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