Transcription of IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM …
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IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM …
STATE OF california - HEALTH AND HUMAN SERVICES AGENCY california department OF social SERVICES . IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM AND. WAIVER PERSONAL CARE SERVICES (WPCS) PROGRAM . LIVE-IN self -CERTIFICATION FORM FOR FEDERAL AND. STATE TAX WAGE EXCLUSION. Provider Name Recipient Name Provider Number Recipient Case Number County Of Residence ALL INFORMATION MUST BE COMPLETED. SEE BACK OF FORM FOR INSTRUCTIONS. Provider self -Certification By completing this form, you are certifying that the wages you receive for providing IHSS. and/or WPCS SERVICES to the recipient named above will be excluded from your federal and state personal income taxes. Under penalties of perjury, I declare that I am a provider receiving payments under the IHSS and/or WPCS programs for care I provide to _____, who lives with me in the same home.
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES SOC 2298 (12/16) PAGE 2 OF 2 Instructions for filling out the Live-In Self-Certification Form
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