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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 . and/or WPCS SERVICES to the recipient named above will be excluded from your federal and state personal income taxes.

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 soc 2298 (1/19) page 1 of 2 ... ihss – irs live-in self-certification p.o. box 1677 west sacramento, ca 95691-6677.

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