Form IHSS-E003 "In-home Supportive Services (Ihss) Program Notice to Recipient for Discontinuance of Exemption From Workweek Limitations for Extraordinary Circumstances" - California

What Is Form IHSS-E003?

This is a legal form that was released by the California Department of Social Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2017;
  • The latest edition provided by the California Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form IHSS-E003 by clicking the link below or browse more documents and templates provided by the California Department of Social Services.

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Download Form IHSS-E003 "In-home Supportive Services (Ihss) Program Notice to Recipient for Discontinuance of Exemption From Workweek Limitations for Extraordinary Circumstances" - California

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
NOTICE TO RECIPIENT FOR DISCONTINUANCE OF EXEMPTION FROM
WORKWEEK LIMITATIONS FOR EXTRAORDINARY CIRCUMSTANCES
(ADDRESSEE)
COUNTY OF:
Notice Date:
IHSS Office Address:
IHSS Office Telephone:
Recipient Name:
Case Number:
Provider Name:
Provider Number:
To: In-Home Supportive Services (IHSS) Recipient
This notice is to inform you that at the end of service month _________________, the
Month and Year
Exemption From Workweek Limitations for Extraordinary Circumstances (Exemption 2)
will be discontinued for your IHSS provider listed above because:
Your provider is no longer providing services for one or more of the recipients
for which the exemption was granted.
Your provider no longer resides with one or more of the recipients for which the
exemption was granted.
One or more of the recipients for which the exemption was granted has had a
reduction in authorized IHSS hours, which allows your provider to work within
the workweek limitations.
One or more of the recipients for which the exemption was granted no longer
meets the criteria for an Exemption 2.
The recipient(s) have hired an additional provider(s) and therefore, your
provider is able to comply with the workweek limitations
OTHER: _______________________________________________________
_______________________________________________________________
_______________________________________________________________
IHSS-E 003 (1/17)
PAGE 1 OF 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
NOTICE TO RECIPIENT FOR DISCONTINUANCE OF EXEMPTION FROM
WORKWEEK LIMITATIONS FOR EXTRAORDINARY CIRCUMSTANCES
(ADDRESSEE)
COUNTY OF:
Notice Date:
IHSS Office Address:
IHSS Office Telephone:
Recipient Name:
Case Number:
Provider Name:
Provider Number:
To: In-Home Supportive Services (IHSS) Recipient
This notice is to inform you that at the end of service month _________________, the
Month and Year
Exemption From Workweek Limitations for Extraordinary Circumstances (Exemption 2)
will be discontinued for your IHSS provider listed above because:
Your provider is no longer providing services for one or more of the recipients
for which the exemption was granted.
Your provider no longer resides with one or more of the recipients for which the
exemption was granted.
One or more of the recipients for which the exemption was granted has had a
reduction in authorized IHSS hours, which allows your provider to work within
the workweek limitations.
One or more of the recipients for which the exemption was granted no longer
meets the criteria for an Exemption 2.
The recipient(s) have hired an additional provider(s) and therefore, your
provider is able to comply with the workweek limitations
OTHER: _______________________________________________________
_______________________________________________________________
_______________________________________________________________
IHSS-E 003 (1/17)
PAGE 1 OF 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
This discontinuance means your provider will be subject to comply with the existing
workweek limitations. Therefore, the maximum number of hours that your provider
may work in a workweek for two (2) or more recipients combined is 66 hours. If your
provider submits timesheets that report working hours that exceed the 66 hour
workweek limitations after the effective date of the discontinuance, your provider will
accrue a violation.
Either you or one of the other recipient(s) your provider works for will need to hire
another IHSS provider(s) to work any remaining authorized IHSS hours above the 66
hour per workweek limit. Please discuss and make arrangements with your provider to
ensure that workweek limits are not exceeded.
If you have any questions, please contact your IHSS County Social Worker at the IHSS
office telephone number above.
IHSS-E 003 (1/17)
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