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IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM AND …

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.

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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