Form SOC2308 "Exemption From Workweek Limits for Extraordinary Circumstances Approved Exemption Provider Agreement - in-Home Supportive Services (IHSS) Program" - California

What Is Form SOC2308?

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 February 1, 2018;
  • 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 SOC2308 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 SOC2308 "Exemption From Workweek Limits for Extraordinary Circumstances Approved Exemption Provider Agreement - in-Home Supportive Services (IHSS) Program" - California

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State of California – Health and Human Services Agency
California Department of Social Services
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
EXEMPTION FROM WORKWEEK LIMITS FOR EXTRAORDINARY
CIRCUMSTANCES APPROVED EXEMPTION PROVIDER AGREEMENT
Provider Name:
Provider Number:
Recipient #1 Name:
Case #:
Recipient #2 Name:
Case #:
Recipient #3 Name:
Case #:
Recipient #4 Name:
Case #:
By signing below, I acknowledge, understand and agree that, as a condition of being
granted an exemption from the IHSS Program workweek limits, I hereby certify to abide
by all of the following conditions:
The exemption applies only to the services I provide for the above-named recipients.
I may not work for an individual recipient more than that recipient’s monthly
authorized hours.
The maximum combined total number of authorized hours I can work for the above-
named recipients shall not exceed 360 hours per month.
Working over 360 authorized hours per month may lead to me being ineligible to be
a provider in the IHSS Program.
If my recipients’ combined authorized hours total more than 360 per month, one or
more of my recipients will need to hire another provider to work the hours above 360
per month.
I will notify the county of any changes in my employment and living arrangements
within 15 calendar days of the change. If I no longer work for the above-named
recipients or, in certain circumstances, if I no longer live in the same home as the
recipients, the exemption will be rescinded and I will be subject to the standard
workweek limits. In that case, the maximum number of hours I will be able to work
for two or more recipients combined is up to 66 hours in a workweek.
Provider Signature:
Date:
Please keep a copy of this signed agreement for your records and return the
original to:
_____________________________________
_____________________________________
___________________, CA ______________
SOC 2308 (2/18)
Page 1 of 1
State of California – Health and Human Services Agency
California Department of Social Services
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
EXEMPTION FROM WORKWEEK LIMITS FOR EXTRAORDINARY
CIRCUMSTANCES APPROVED EXEMPTION PROVIDER AGREEMENT
Provider Name:
Provider Number:
Recipient #1 Name:
Case #:
Recipient #2 Name:
Case #:
Recipient #3 Name:
Case #:
Recipient #4 Name:
Case #:
By signing below, I acknowledge, understand and agree that, as a condition of being
granted an exemption from the IHSS Program workweek limits, I hereby certify to abide
by all of the following conditions:
The exemption applies only to the services I provide for the above-named recipients.
I may not work for an individual recipient more than that recipient’s monthly
authorized hours.
The maximum combined total number of authorized hours I can work for the above-
named recipients shall not exceed 360 hours per month.
Working over 360 authorized hours per month may lead to me being ineligible to be
a provider in the IHSS Program.
If my recipients’ combined authorized hours total more than 360 per month, one or
more of my recipients will need to hire another provider to work the hours above 360
per month.
I will notify the county of any changes in my employment and living arrangements
within 15 calendar days of the change. If I no longer work for the above-named
recipients or, in certain circumstances, if I no longer live in the same home as the
recipients, the exemption will be rescinded and I will be subject to the standard
workweek limits. In that case, the maximum number of hours I will be able to work
for two or more recipients combined is up to 66 hours in a workweek.
Provider Signature:
Date:
Please keep a copy of this signed agreement for your records and return the
original to:
_____________________________________
_____________________________________
___________________, CA ______________
SOC 2308 (2/18)
Page 1 of 1