Arnold Schwarzenegger's proposed budget for the 2009-10 fiscal year was released last week, suggesting tax hikes coupled with billi SOC 2302 (5/19) - In-Home Supportive Services (IHSS) Program Provider Paid Sick Leave Request Form. The form must be submitted to the county in person and . These behaviors must be regularly occurring and random. Click here: Tips for Using Adobe PDF Files, California COVID-19 Only Paid Sick Leave Request Form For IHSS/WPCS Providers, TEMP 3022(8/21) - Important Information For CalWORKs Families -State Law Increases The CalWORKs Time Limit To 60 Months, TEMP 3023(3/22) - Income Exemption Request Coversheet, Copyright 2023 California Department of Social Services, QR 2103 (11/11) - Reminder For Teens Turning 18 Years Old, RAD 03 (2/21) Suspected Unemployment Insurance Fraud And identity Theft Information, RAD 04 (12/21) Work Participation Rate Request for Policy Interpretation, RCA 43 (5/03) - Refugee Cash Assistance (RCA) Notice Of A Participation Problem, RCA 44 (5/03) - Refugee Cash Assistance (RCA) Notice Of No Good Cause Determination And Compliance Plan Appointment, RFA 00 (8/17) - Conversion to Resource Family: Release of Information, RFA 00A (2/17) - Conversion - Resource Family Application, RFA 01A (10/22) - Resource Family Application, RFA 01B (5/21) - Resource Family Criminal Record Statement, RFA 02 (3/22) - Resource Family Background Checklist, RFA 03 (8/22) - Resource Family Home Health And Safety Assessment Checklist, RFA 04 (11/13) - Resource Family Risk Assessment, RFA 05 (1/23) - Resource Family Approval - Written Report, RFA 05A (8/22) - Resource Family Approval Certificate, RFA 05C (8/18) - Resource Family Approval - Written Report (Conversion), RFA 06 (11/18) - Resource Family Approval: Update Report, RFA 07 (2/18) - Resource Family Approval (RFA) Health Questionnaire, RFA 09 (1/18) - Notice Of Action Regarding Resource Family Approval, RFA 09B (4/18) - Notice Of Action To Individual Regarding Resource Family Approval Criminal Record Exemption Decision, RFA 09E (9/17) - Order To Individual of Exclusion From Resource Family Homes And Department Licensed Facilities, RFA 09I (9/17) - Order To Individual Of Immediate Exclusion From Resource Family Homes And Department Licensed Facilities, RFA 10 (12/19) Resource Family Approval Portability Application, RFA 11 (12/19) Resource Family Approval Statement Acknowledging Requirement To Report Child Abuse, RFA 12 (3/21) - Resource Family Approval Documented Alternative Plan (DAP), RFA 100 (9/18) - Notice Of Action - Issuance Interim Funding For Emergency Caregivers, RFA 100A (9/18) - Notice Of Action - Discontinue Interim Funding For Emergency Caregivers, RFA 105 (11/19) Notice of Action Issuance Emergency Caregiver Funding, RFA 105A (11/19) Notice of Action Discontinue Emergency Caregiver Funding, RFA 809 (4/21) - Resource Family Visit Record, RFA 809C (9/17) - Resource Family Visit Corrective Action Plan, RFA 812 (6/17) - Detail Supportive Information, RFA 9099 (10/17) - Complaint Investigation Report, RFA 9099C (9/17) - Complaint Investigation Report - Continued, RS 1 (3/08) - Refugee Settlement Program Services Application And Assessment Information, RS 3 (10/03) - Service Provider Referral/Notification Form, RS 18 (5/03) - Refugee Services - Information Transmittal, RS 36 (3/08) - Employment And Training Requirements For Refugee Cash Assistance (RCA), SAR 2 (6/19) - Reporting Changes For Cash Aid And CalFresh, SAR 2LP (6/19) - Reporting Changes For Cash Aid and CalFresh, SAR 3 (2/15) - Mid-Period Status Report For Cash Aid and CalFresh, SAR 7 (12/14) - SAR 7 Eligibility Status Report, SAR 7 Addendum (4/13) - Instructions And Penalties SAR 7 Eligibility Status Report - For Cash Aid and CalFresh, SAR 7A (12/14) - How To Fill Out Your SAR 7 Eligibility Status Report, SAR 22 (3/13) - Sponsored NonCitizens Applying For Or Receiving Cash Aid And/Or CalFresh, SAR 22LP (3/13) - Sponsored NonCitizens Applying For Or Receiving Cash Aid And/Or CalFresh - (Large Print), SAR 23 (3/13) - Senior Parent Statement Of Facts, SAR 72 (3/13) - Sponsor's Semi-Annual Income And Resources Report, SAR 73 (3/13) - Senior Parent Semi-Annual Income Report, SAWS 1 (8/13) - Initial Application For CalFresh, Cash Aid, And/Or Medi-Cal/Health Care Programs, SAWS 2A SAR (4/15) - Rights and Responsibilities And Other Important Information For The Cash Aid And CalFresh Programs, And/Or Medi-Cal/34-County Medical Services Program (CMSP), SAWS 2A SAR LP (4/15) - Rights and Responsibilities And Other Important Information For The Cash Aid And CalFresh Programs, And/Or Medi-Cal/34-County Medical Services Program (CMSP), SAWS 2 PLUS (4/15) - Application For CalFresh, Cash Aid, And/Or Medi-Cal/Health Care Programs, SAWS 2 PLUS LP (4/15) - Application For CalFresh, Cash Aid, And/Or Medi-Cal/Health Care Programs, SAWS 30 (3/19) - Notification Of New Employment, SCC12 (11/99) - Registration Fee Worksheet For 75th Percentile Regional Market Rate (RMR) Ceiling Level, SDFAP 01 (12/19) - State Disaster Food Assistance Program (SDFAP) Certification Of Eligibility, SDFAP 02 (12/19) - State Disaster Food Assistance Program (SDFAP) Tracking Report, SNB 1 (8/18) - Notice To CalFresh Recipients Supplemental Nutrition Benefit (SNB) Program, SNB 2 (8/18) - Notice Of Approval For Supplemental Nutrition Benefit (SNB) Program, SNB 3 (8/18) - Notice Of Change For Supplemental Nutrition Benefit (SNB) Program, SNB 4 (8/18) - Notice Of Expiration Of Certification For Supplemental Nutrition Benefit (SNB) Program, SNB 5 (8/18) - Notice Of Discontinuance For Supplemental Nutrition Benefit (SNB) Program, SNB 7 (6/19) - CalFresh And Supplemental Nutrition Benefit (SNB) Informing Notice Of Receiving Intercounty Transfer, SNB 8 (6/19) - CalFresh And Supplemental Nutrition Benefit (SNB) Informing Notice Of Sending Intercounty Transfer, SOC 152 (9/19) - Placement Agency - THP Plus Foster Care Provider Agreement - Nonminor Dependent Placed By Agency In THP Plus Foster Care Provider, SOC 153 (9/19) -Placement Agency - Foster Family Agency Agreement Nonminor Dependent Placed by Agency in Foster Family Agency, SOC 154 (9/19) -Agency Group Home Agreement Child Placed by Agency in Group Home, SOC 154A (7/20) - Placement Agency - Foster Family Agency Agreement Child Placed By Agency In Foster Family Agency, SOC 154B (1/12) - Agency - Group Home Agreement Nonminor Dependent Placed By Agency In Group Home, SOC 154C (9/20) Agency - Short-Term Residential Therapeutic Program (STRTP) Admission Agreement Child Placed By Agency Into STRTP, SOC 155 (5/99) - Voluntary Placement Agreement - Placement Request, SOC 155B (3/00) - Mutual Agreement For 18 Year Olds, SOC 155C (1/00) - Voluntary Placement Agreement Parent/Agency (Indian Child), SOC 156 (9/19) -Agency Foster Parents Agreement Child Placed by Agency in Foster Home, SOC 156A (9/19) - Agency - Foster Parents Placement Agreement Nonminor Dependent Placed By Agency In Foster Home, SOC 157A (8/17) - Supervised Independent Living Placement Approval And Placement Agreement, SOC 157B (7/17) - SILP Inspection: Checklist Of Facility Health And Safety Standards, SOC 157C (7/17) - Standardized SILP Readiness Assessment Tool, SOC 158A (2/05) - Foster Child's Data Record And AFDC-FC Certification, SOC 160 (2/10) - Foster Family Agency (FFA) CWS/CMS Contact/Service Delivery Log, SOC 161 (9/11) - Six-Month Certification Of Extended Foster Care Participation, SOC 162 (7/18) - Mutual Agreement for Extended Foster Care, SOC 163 (7/18) - Voluntary Re-Entry Agreement For Extended Foster Care, SOC 170 (5/12) - Application To Become A Transitional Housing Program (THP)-Plus-Foster Care Provider, SOC 171 (5/12) - Transitional Housing Program-Plus-Foster Care (THP-Plus-FC) Application - Approval/Denial/Denial Pending Checklist, SOC 177 (5/12) - Facility Evaluation Report -Transitional Housing Program-Plus-Foster Care Facility, SOC 179 (8/12) - Transitional Housing Program Plus Foster Care (THP+FC)- Non-Minor Dependent Rate Application, SOC 294A (3/02) - IHSS Income Eligibility - Adult, SOC 294C (11/99) - IHSS Income Eligibility - Child, SOC 295 (9/18) - Application For In-Home Supportive Services, SOC 295L (9/18) Application For In-Home Supportive Services, SOC 310 (1/03) - Statement Of Facts For In-Home Supportive Services, SOC 312 (5/00) - In-Home Supportive Services Special Pre-Authorized Transactions, SOC 321 (11/99) - Request For Order And Consent - Paramedical Services, SOC 330 (3/01) - In-Home Supportive Services Overpayment Collection Transaction, SOC 332 (9/09) - In-Home Supportive Services (Recipient/Employer Responsibility Checklist), SOC 332L (1/19) - In-Home Supportive Services (Recipient/Employer Responsibility Checklist), SOC 341 (8/22) - Report Of Suspected Dependent Adult/Elder Abuse, SOC 341A (6/22) - Statement Acknowledging Requirement To Report Suspected Abuse Of Dependent Adults And Elders, SOC 342 (6/22) - Report Of Suspected Dependent Adult/Elder Financial Abuse - For Use By Financial Institutions, SOC 343 (6/01) - Investigation of Suspected Dependent Adult/Elder Abuse, SOC 369 (12/10) - Agency-Relative Guardianship Disclosure, SOC 369A (7/15) - Kinship Guardianship Assistance Payment (Kin-GAP) Program Agreement Amendment, SOC 371 (7/20) Grant/Grant Amendment Transaction Request, SOC 383 (5/02) - Child Welfare Services Application, SOC 404 (10/11) - In-Home Supportive Services Program Direct Deposit Enrollment/Change/Cancellation Form, SOC 409 (2/23) - IHSS/CMIPS Elective State Disability Insurance (SDI) Form, SOC 425 (7/03) - Physician's Certification Of Medical Necessity, SOC 426 (2/23) - In-Home Supportive Services (IHSS) Program Provider Enrollment Form, SOC 426A (2/23) - In-Home Supportive Services (IHSS) Program Recipient Designation Of Provider, SOC 426C (10/10) - In-Home Supportive Services (IHSS) Program California Code Sections, SOC 431 (5/03) - Personal Care Services Program Contract Agency Enrollment, SOC 432 (8/04) - Claim For Reimbursement In-Home Supportive Services Program Contract Expenditures, SOC 445 (6/99) - Medi-Cal Recovery For The Personal Care Services Program, SOC 450 (2/23) - Voluntary Services Certification, SOC 452 (6/19) - Cash Assistance Program For Immigrants (CAPI) Income Eligibility - Adult, SOC 452A (8/05) - Cash Assistance Program For Immigrants (CAPI) Income Eligibility Child, SOC 453 (8/22) - Cash Assistance Program For Immigrants (CAPI) Statement Of Household Expenses And Contributions, SOC 454 (4/99) - Cash Assistance Program For Immigrants (CAPI) Sponsor To Alien Deeming Worksheet, SOC 455 (1/99) - Authorization for State Reimbursement of Interim Assistance, SOC 804 (2/20) - Statement Of Facts For Determining Continuing Eligibility For The Cash Assistance Program For Immigrants (CAPI), SOC 807 (7/00) - Cash Assistance Program For Immigrants (CAPI) Request For Waiver Of Overpayment Recovery - Income/Expenses, SOC 807A (7/00) - Cash Assistance Program For Immigrants (CAPI) Request For Waiver Of Overpayment Recovery - Without Fault, SOC 809 (10/16) - Cash Assistance Program For Immigrants (CAPI) Indigence Exception Statement, SOC 810 (2/02) - Applicant Certification Of Contact With SSA To Change Status From Institutional Care To A Home Setting, SOC 811 (4/02) - In-Home Supportive Services (IHSS) Sponsor To Alien Deeming Worksheet (20 CFR 416.1166a), SOC 812A (7/13) - Abatements Not Processed Through The County Expense Claim, SOC 812B (7/13) - Abatements Not Processed Through The CA 800 Claim, SOC 813 (8/20) - Cash Assistance Program For Immigrants (CAPI) Indigence Exception Determination, SOC 814 (12/20) - Statement Of Facts Cash Assistance Program For Immigrants (CAPI), SOC 815 (1/12) - Approval of Family Caregiver Home, SOC 817 (12/10) - Checklist Of Health And Safety Standards For Approval Of Family Caregiver Home, SOC 817 NMD (1/12) - Checklist of Health And Safety Standards For Approval of Family Caregiver Home, SOC 818 (12/10) - Relative Or Non-Relative Extended Family Member Caregiver Assessment, SOC 818 NMD (1/12) - Relative Or Non-Relative Extended Family Member Caregiver Assessment, SOC 820 (10/04) - Notice Of Involuntary Child Custody Proceedings For An Indian Child (Juvenile Court), SOC 821 (3/06) - Assessment Of Need For Protective Supervision For In-Home Supportive Services Program, SOC 822 (1/06) - CAPI Notification Of Inter-County Transfer, SOC 824 (9/20) - In-Home Supportive Services (IHSS) Quality Assurance/Quality Improvement (QA/QI) Quarterly Activities, SOC 825 (2/23) - Protective Supervision 24-Hours-A-Day Coverage Plan, SOC 826 (11/18) - Child Fatality/Near Fatality County Statement Of Findings And Information, SOC 826A (11/16) - Child Near Fatality - County Report Of Services Provided And Actions Taken, SOC 827 (2/23) - IHSS Program Individual Emergency Back-Up Plan, SOC 828 (1/07) - Conlan II County Verificiation, SOC 829 (10/18) - In-Home Supportive Services (IHSS) / Waiver Personal Care Services (WPCS) Provider Direct Deposit Enrollment/Change/Cancellation Form, SOC 830 (9/22) - Request for Conditional CAPI After Naturlization Pending SSI/SSP Eligiblity Determination, SOC 832 (1/13) - Notice of Child Abuse Central Index Listing, SOC 833 (3/12) - Grievance Procedures for Challenging Reference to the Child Abuse Central Index, SOC 834 (3/13) - Request for Grievance Hearing, SOC 835 (11/08) - Supplement To The Dual Agency Rate - Multiple Questionnaire Worksheet, SOC 836 (11/08) - Supplement To The Rate Eligibility Form, SOC 837 (11/08) - Supplement To The Rate Questionnaire, SOC 838 (10/12) - In-Home Supportive Services (IHSS) Recipient Request For Assignment Of Authorized Hours To Providers, SOC 839 (6/18) - In-Home Supportive Services (IHSS) Designation Of Authorized Representative, SOC 839A (5/18) - In-Home Supportive Services (IHSS) Cancellation Of Authorized Representative, SOC 840 (10/12) - In-Home Supportive Services (IHSS) Program Provider Or Recipient Change Of Address And/Or Telephone, SOC 846 (10/19) - In-Home Supportive Services (IHSS) Program Provider Enrollment Agreement, SOC 847 (5/16) - Important Information For Prospective Providers About The In-Home Supportive Services (IHSS) Program Provider Enrollment Process, SOC 848 (2/20) - In-Home Supportive Services Program Notice Of Provider Eligibility, SOC 848A (5/16) - In-Home Supportive Services Program Lapse of Ten-Year Timeframe for Tier 2 Crime, SOC 849 (9/22) In-House Supportive Services Program Notice Of Incomplete Provider Enrollment Form, SOC 850 (10/09) - In-Home Supportive Services Program Notice Of Provider Ineligibility, SOC 851 (5/16) - In-Home Supportive Services Program Notice To Applicant Provider Of Provider Ineligibility Incomplete Provider Process, SOC 851A (5/16) - In-Home Supportive Services Program Notice To Applicant Provider Of Incomplete Provider Process 15-Day Notification, SOC 852 (1/11) - In-Home Supportive Services Program Notice Of Provider Ineligibility Tier 1 Crimes (Elder Or Dependent Adult Abuse/Child Abuse & Fraud Against A Government Health Care Of Supportive Services Program), SOC 852A (5/16) - IHSS Program Notice To Provider Applicant Of Provider Ineligibility Tier 2 Crimes (Serious/Violent Felonies; Sex Offender Felonies; Fraud Against Government Agencies), SOC 853 (10/09) - In-Home Supportive Services Program Notice Of Provider Ineligibility, SOC 854 (1/11) - In-Home Supportive Services Program Notice To Recipient Of Provider Eligibility, SOC 854L (10/18) - In-Home Supportive Services Program Notice To Recipient Of Provider Eligibility, SOC 855 (5/16) - In-Home Supportive Services Program Notice To Recipient Of Provider Ineligibility Incomplete Provider Process, SOC 855L (10/18) - In-Home Supportive Services Program Notice To Recipient Of Provider Ineligibility Incomplete Provider Process, SOC 855A (1/11) - IHSS Program Notice To Recipient Of Provider Ineligibility Tier 1 Crimes (Elder Or Dependent Adult Abuse/Child Abuse & Fraud Against A Government Health Care Or Supportive Services Program), SOC 855AL (10/18) - IHSS Program Notice To Recipient Of Provider Ineligibility Tier 1 Crimes (Elder Or Dependent Adult Abuse/Child Abuse & Fraud Against A Government Health Care Or Supportive Services Program), SOC 855B (5/16) - IHSS Program Notice To Recipient Of Provider Ineligibility Tier 2 Crimes (Serious/Violent Felonies; Sex Offender Felonies; Fraud Against Government Agencies), SOC 855BL (10/18) - IHSS Program Notice To Recipient Of Provider Ineligibility Tier 2 Crimes (Serious/Violent Felonies; Sex Offender Felonies; Fraud Against Government Agencies), SOC 856 (7/19) - To Request Appeal Of Provider Enrollment Denial, SOC 856L (1/19) - To Request Appeal Of Provider Enrollment Denial, SOC 857 (5/16) - IHSS Program Notice To Recipient Of Provider Eligibility Acknowledgement Of Receipt Of Waiver, SOC 857L (10/18) - IHSS Program Notice To Recipient Of Provider Eligibility Acknowledgement Of Receipt Of Waiver, SOC 857A (4/12) - In-Home Supportive Services (IHSS) Program Notice To Recipient Of Provider Ineligibility Acknowledgement Of Receipt Of Invalid Request For Provider Waiver, SOC 857AL (10/18) - In-Home Supportive Services (IHSS) Program Notice To Recipient Of Provider Ineligibility Acknowledgement Of Receipt Of Invalid Request For Provider Waiver, SOC 857B (6/16) - In-Home Supportive Services Program Notice To Provider Of Provider Ineligibility Criminal Background Check Needed, SOC 858 (12/11) - In-Home Supportive Services Provider Notification, SOC 858A (1/11) - IHSS Program Notice To Provider Of Provider Ineligibility Tier 1 Crimes Ineligibility - Subsequent Conviction, SOC 858B (5/16) - IHSS Program Notice To Provider Of Provider Ineligibility Tier 2 Crimes Ineligibility - Subsequent Conviction, SOC 859A (1/11) - IHSS Program Notice To Recipient Of Provider Ineligibility Tier 1 Crimes Ineligibility - Subsequent Conviction, SOC 859AL (10/18) - IHSS Program Notice To Recipient Of Provider Ineligibility Tier 1 Crimes Ineligibility - Subsequent Conviction, SOC 859B (5/16) - IHSS Program Notice To Recipient Of Provider Ineligibility Tier 2 Crimes Ineligibility - Subsequent Conviction, SOC 859BL (10/18 ) - IHSS Program Notice To Recipient Of Provider Ineligibility Tier 2 Crimes Ineligibility - Subsequent Conviction, SOC 860 (7/18) - Cash Assistance Program for Immigrants (CAPI) Sponsor's Statement Of Facts Income And Resources, SOC 861 (10/10) - Safely Surrendered Baby Medical Questionnaire, SOC 862 (5/16) - In-Home Supportive Services (IHSS) Recipient Request For Provider Waiver, SOC 862L (10/18) - In-Home Supportive Services (IHSS) Recipient Request For Provider Waiver, SOC 863 (5/19) - In-Home Supportive Services (IHSS) Applicant Provider Request For General Exception, SOC 864 (3/11) - In-Home Supportive Services (IHSS) Program Individualized Back-up Plan and Risk Assessment, SOC 865 (7/12) - IHSS Request For Applicant Provider Reference, SOC 865L (10/18) - IHSS Request For Applicant Provider Reference, SOC 870 (5/16) - In-Home Supportive Services Program (IHSS) Notice To Provider Of Provider Eligibility Acknowledgment Of Receipt Of Waiver, SOC 871 (7/12) - Statement Of Facts (SOF) Summary Sheet IHSS Program Caregiver Background Check Bureau (CBCB, General Exception Unit (GEU), SOC 872 (7/12) - Statement Of Facts (SOF) Preparation Checklist IHSS Program Caregiver Background Check Bureau (CBCB), General Exception Unit (GEU), SOC 873 (10/16) - In-Home Supportive Services (IHSS) Program Health Care Certification Form, SOC 873L (1/19) - In-Home Supportive Services (IHSS) Program Health Care Certification Form, SOC 874 (10/16) - In-Home Supportive Services (IHSS) Program Notice To Applicant Of Health Care Certification Requirement, SOC 874L (1/19) - In-Home Supportive Services (IHSS) Program Notice To Applicant Of Health Care Certification Requirement, SOC 875 (11/11) - In-Home Supportive Services (IHSS) Program Notice To Recipient Of Health Care Certification Requirement, SOC 875L (10/18) - In-Home Supportive Services (IHSS) Program Notice To Recipient Of Health Care Certification Requirement, SOC 876 (5/17) - In-Home Supportive Services (IHSS) Program Notice Of Provisional Approval Health Care Certification Exception Granted, SOC 876L (10/18) - In-Home Supportive Services (IHSS) Program Notice Of Provisional Approval Health Care Certification Exception Granted, SOC 880 (11/11) - Safely Surrendered Baby - Report To The California Department of Social Services, SOC 881 (6/12) - In-Home Supportive Services Program Notice To Provider Of Inactivity, SOC 882 (12/16) - County CMIPS II User ID Confirmation CDSS Copy, SOC 883 (8/13) - County CMIPS II User Request Form Deactivate/Reactivate User, SOC 884 (8/12) - County CMIPS II User Request Form Add/Modify User, SOC 885 (6/13) - In-Home Supportive Services (IHSS) Program Notice Of Denial Of Request For In-Home Reassessment Based On State Law Change, SOC 886 (12/15) - Social Worker Disclosure Report, SOC 887 (12/20) - Cash Assistance Program For Immigrants (CAPI) Nonmedical Out-Of-Home Care (NMOHC) Payment Standard Eligibility Determination, SOC 887A (12/20) - Cash Assistance Program For Immigrants (CAPI) Nonmedical Out-Of-Home Care (NMOHC) Payment Standard Eligibility Determination - Retroactive Certification of NMOHC Payment Standard Eligibility, SOC 888 (1/22) FFPSA Voluntary Placement Agreement For Placing A Child With A Parent In A Substance Abuse Treatment Facility, SOC 889 (1/23) - ICWA Hotline Disclosure Report, SOC 2245 (9/20) - In-Home Supportive Services (IHSS) Fraud Data Reporting Form, SOC 2247 (1/14) - IHSS UHV Findings Report, SOC 2248 (7/21) - IHSS Complaint Of Suspected Fraud Form, SOC 2249 (3/14) - Qualified Agency Certification Application Checklist, SOC 2250 (3/14) - Application For Qualified Agency Certification, SOC 2251 (1/14) - To Request Appeal Of Agency Certification Denial, SOC 2255 (3/19) - In-Home Supportive Services (IHSS) Program Provider Workweek & Travel Time Agreement, SOC 2256 (11/15) - In-Home Support Services Program Recipient And Provider Workweek Agreement, SOC 2257 (12/17) - In-Home Supportive Services Program Notice To Provider Of Violation For Exceeding Workweek And/Or Travel Time Limits, SOC 2257A (12/17) - In-Home Supportive Services Program Notice To Recipient Of Providers Violation For Exceeding Workweek And/Or Travel Time Limits, SOC 2257B (3/16) - In-Home Supportive Services Program Notice To Provider Of Second Violation No Record Of Completion Of Review Of Instructional Materials, SOC 2257C (3/16) - In-Home Supportive Services Program Notice To Provider Of Second Violation For Exceeding Workweek And/Or Travel Time Limits, SOC 2258 (3/16) - In-Home Supportive Services Program Notice To Provider Of Third Violation (90-Day Suspension Of Eligibility) For Exceeding Workweek And/Or Travel Time Limits, SOC 2258A (3/16) - In-Home Supportive Services Program Notice To Recipient Of Providers Third Violation (90-Day Suspension Of Eligibility) For Exceeding Workweek And/Or Travel Time Limits, SOC 2259 (3/16) - In-Home Supportive Services Program Notice To Provider Of Fourth Violation (One-Year Period Of Ineligibility) For Exceeding Workweek And/Or Travel Time Limits, SOC 2259A (3/16) - In-Home Supportive Services Program Notice To Recipient Of Providers Fourth Violation (One-Year Period Of Ineligibility) For Exceeding Workweek And/Or Travel Time Limits, SOC 2263 (3/16) In-Home Supportive Services Program Notice To Provider Rescinding Violation, SOC 2264 (3/16) In-Home Supportive Services Program Notice To Recipient Rescinding Provider Violation, SOC 2265 (3/16) - In-Home Supportive Services Program Notice To Provider Reduction Of Total Violation Count, SOC 2266 (1/16) - In-Home Supportive Services Program Notice To Recipient Approval Of Exception To Exceed Weekly Hours, SOC 2266A (1/16) - In-Home Supportive Services Program Notice To Provider Approval Of Exception To Exceed Weekly Hours, SOC 2267 (1/16) - In-Home Supportive Services Program Notice To Recipient Denial Of Exception To Exceed Weekly Hours, SOC 2267A (1/16) - In-Home Supportive Services Program Notice To Provider Denial Of Exception To Exceed Weekly Hours, SOC 2268 (1/16) - In-Home Supportive Services Program Notice To Recipient Approval For Provider To Work Alternate Schedule Due To Recurring Event, SOC 2268A (1/16) - In-Home Supportive Services Program Notice To Provider Approval To Work Alternate Schedule Due To Recurring Event, SOC 2269 (1/16) In-Home Supportive Services Program Notice To Recipient Cancellation Of Alternate Schedule Due To Recurring Event, SOC 2269A (1/16) In-Home Supportive Services Program Notice To Provider Cancellation Of Alternate Schedule Due To Recurring Event, SOC 2270 (2/16) In-Home Supportive Services Program Notice To Recipient Failure To Complete Workweek Agreement (SOC 2256), SOC 2270A (1/16) In-Home Supportive Services Program Notice To Provider Failure To Complete Workweek And Travel Agreement (SOC 2255), SOC 2271 (3/21) - In-Home Supportive Services (IHSS) Program Provider Notification Of Recipient Authorized Hours And Services And Maximum Weekly Hours, SOC 2271A (11/15) - In-Home Supportive Services (IHSS) Program Recipient Notice Of Maximum Weekly Hours, SOC 2272 (7/16) In-Home Supportive Services Program Notice To Provider Of Right To Dispute Violation For Exceeding Workweek And/Or Travel Time Limits, SOC 2272A (4/16) - In-Home Supportive Services Program Notice To Provider Acknowledgement Of Receipt Of County Violation Review, SOC 2272B (4/16) - In-Home Supportive Services Program Notice To Recipient Acknowledgement Of Provider's Request For County Violation Review For Exceeding Workweek And/or Travel Time Limits, SOC 2273 (11/18) - In-Home Supportive Services Program Request For State Administrative Review Of Third Or Fourth Violation For Exceeding Workweek And/Or Travel Time Limits, SOC 2274 (11/14) - In-Home Supportive Services (IHSS ) Program Accompaniment To Medical Appointment, SOC 2277 (2/15) - Contract Mode Service Report, SOC 2278 (1/15) - IHSS Qualified Agency Change Of Ownership Form, SOC 2279 (1/16) - In-Home Supportive Services (IHSS) Program Live-In Family Care Provider Overtime Exemption, SOC 2280 (6/16) - In-Home Supportive Services Program Notice To Provider Upholding First Or Second Violation For Exceeding Workweek And/Or Travel Time Limits, SOC 2281 (6/16) - In-Home Supportive Services Program Notice To Recipient Upholding Providers First Or Second Violation For Exceeding Workweek And/Or Travel Time Limits, SOC 2282 (9/18) - In-Home Supportive Services Program Notice To Provider Upholding Third Or Fourth Violation For Exceeding Workweek And/Or Travel Time Limits, SOC 2283 (9/18) - In-Home Supportive Services Program Notice To Recipient Upholding Providers Third Or Fourth Violation For Exceeding Workweek And/Or Travel Time Limits, SOC 2286 (6/16) In-Home Supportive Services Program State Administrative Review Request Response Letter To Provider Upholding Third Violation (90-Day Suspension Of Eligibility) For Exceeding Workweek And/Or Travel Time Limits, SOC 2287 (6/16) In-Home Supportive Services Program State Administrative Review Request Response Letter To Recipient Upholding Providers Third Violation (90-Day Suspension Of Eligibility) For Exceeding Workweek And/Or Travel Time Limits, SOC 2288 (7/16) In-Home Supportive Services Program State Administrative Review Request Response Letter To Provider Rescinding Third Violation Or Fourth Violation For Exceeding Workweek And/Or Travel Time Limits, SOC 2289 (7/16) In-Home Supportive Services Program State Administrative Review Request Response Letter To Recipient Rescinding Providers Third Or Fourth Violation For Exceeding Workweek And/Or Travel Time Limits, SOC 2290 (6/16) In-Home Supportive Services Program State Administrative Review Request Response Letter To Provider Upholding Fourth Violation (One-Year Period Of Ineligibility), SOC 2291 (6/16) In-Home Supportive Services Program State Administrative Review Request Response Letter To Recipient Upholding Fourth Violation (One-Year Period Of Ineligibility), SOC 2292 (1/19) - In-Home Supportive Services Program Notice To Provider Of Failure To Timely Or Completely Submit The Right To Dispute Violation For Exceeding Workweek And/or Travel Time Limits Form (SOC 2272), SOC 2293 (1/19) - In-Home Supportive Services Program Notice To Recipient Of Provider's Failure To Timely Or Completely Submit The Right To Dispute Violation For Exceeding Workweek And/or Travel Time Limits Form (SOC 2272), SOC 2298 (1/19) - 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 2299 (1/19) - In-Home Supportive Services (IHSS) Program And Waiver Personal Care Services (WPCS) Program Live-In Self-Certification Cancellation Form For Federal And State Tax Wage Exclusion, SOC 2300 (2/17) - In-Home Supportive Services Program Notice To Applicant Of Application Confirmation Number, SOC 2301 (4/17) - In-Home Supportive Services (IHSS) Or Waiver Personal Care Services (WPCS) Recipient Confirmation Of Enrollment In Electronic Timesheet Service Or Telephone Timesheet System, SOC 2302 (5/19) - In-Home Supportive Services (IHSS) Program Provider Paid Sick Leave Request Form, SOC 2303 (12/19) - In-Home Supportive Services Program Notice To Provider Of Incomplete Paid Sick Leave Request Form (SOC 2302), SOC 2305 (8/19) - In-Home Supportive Services (IHSS) Program Request For Exemption From Workweek Limits For Extraordinary Circumstances (Exemption 2), SOC 2306 (1/18) - In-Home Supportive Services (IHSS) Program Exemption From Workweek Limits For Extraordinary Circumstances Referral Justification, SOC 2307 (1/18) - In-Home Supportive Services (IHSS) Program Extraordinary Circumstances Secondary Evaluation Worksheet, SOC 2308 (2/18) - In-Home Supportive Services (IHSS) Program Exemption From Workweek Limits For Extraordinary Circumstances Approved Exemption Provider Agreement, SOC 2309 (2/18) - In-Home Supportive Services (IHSS) Program Notice To Provider Of Approval Of Exemption From The In-Home Supportive Services Program Workweek Limits For Extraordinary Circumstances, SOC 2309A (2/18) - In-Home Supportive Services (IHSS) Program Notice To Recipient Of Approval Of Exemption From The In-Home Supportive Services Program Workweek Limits For Extraordinary Circumstances, SOC 2310 (5/19) - In-Home Supportive Services (IHSS) Program Notice To Provider Of Ineligibility For Exemption From Workweek Limits For Extraordinary Circumstances (Exemption 2), SOC 2310A (5/19) - In-Home Supportive Services (IHSS) Program Notice To Recipient Of Ineligibility For Exemption From Workweek Limits For Extraordinary Circumstances (Exemption 2), SOC 2311 (2/18) - In-Home Supportive Services Program Notice Of Non-Receipt Of Exemption From Workweek Limits Provider Agreement (SOC 2308), SOC 2312 (3/20) - In-Home Supportive Services (IHSS) Program Notice To Provider Of Termination Of Exemption From Workweek Limits For Extraordinary Circumstances (Exemption 2) Due To A Change In Eligibility, SOC 2312A (3/20) - In-Home Supportive Services (IHSS) Program Notice To Recipient Of Termination Of Exemption From Workweek Limits For Extraordinary Circumstances (Exemption 2) Due To A Change In Eligibility, SOC 2313 (3/20) - In-Home Supportive Services (IHSS) Program Exemption From Workweek Limits For Extraordinary Circumstances (Exemption 2) State Administrative Review Request Form, SOC 2320 (10/17) - In-Home Supportive Services (IHSS) And Waiver Personal Care Services (WPCS) CDSS Violation Removal Request, SOC 2323 (12/18) - In-Home Supportive Services Program Provider Requirements For Minor Recipients Living With Their Parents, SOC 2324 (1/19) - In-Home Supportive Services (IHSS) Program County Or Public Authority (PA) Request To Remove Criminal Offender Record Information (CORI) From The Case Management, Information And Payrolling System (CMIPS), SOC 2325 (9/19) - In-Home Supportive Services Program Notice To Provider Of Non-Acceptance Of Subsequent Request For Exemption From Workweek Limits For Extraordinary Circumstances (Exemption 2), In-Home Supportive Services (IHSS) Recipients Responsibility To Stop Sexual Harassment In The Workplace, In-Home Supportive Services (IHSS) Providers Right To File A Sexual Harassment Complaint, SR 1 (12/04) - Group Home Program Rate Application (SR 1), SR 1A (4/17) - Short-Term Residential Therapeutic Program (STRTP) Rate Application (SR 1A), SR 2 (12/04) - Program Classification Report, SR 2A (12/02) - Child Care and Supervision Component Program Worksheet, SR 2B (12/02) - Social Work Component Program Worksheet, SR 2C (06/03) - Mental Health Component Program Worksheet, SR 2-WP (12/02) - Entrance Questionnaire (SR 2-WP), SR 2B PHV (6/03) - SW Paid Hours Verification Worksheet, SR 2-DN (1/03) - Documentation Needed (SR 2-DN), SR 3 (12/04) - Group Home Program Cost Report, SR 4 (12/04) - Group Home Program Payroll & Fringe Benefit Report, SR 5 (12/04) - Group Home Program Days Of Care Schedule, SR 8 (5/15) - Financial Audit Report Transmittal, SR 9 (5/15) - Federal Expenditure Certification, SR 10 (5/15) - Certification Of Audited Cost Data, SSGP 45 (11/18) - The State Supplemental Grant Program (SSGP), SSP 14 (9/10) - Authorization For Reimbursement Of Interim Assistance Initial Claim Or Posteligibility Case, SSP 17 (4/99) - Notice Of Action Right To Request A State Hearing On Interim Assistance, SSP 18 (4/15) - Notice Of Action And Right To Request A State Hearing On Interim Assistance.
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