Form SOC2324 "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)" - California

What Is Form SOC2324?

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, 2019;
  • 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;
  • Fill out the form in our online filing application.

Download a fillable version of Form SOC2324 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 SOC2324 "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)" - California

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State of California – Health and Human Services Agency
California Department of Social Services
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)
THIS FORM IS FOR COUNTY/PUBLIC AUTHORITY USE ONLY
County:
Current/Prospective
Current/Prospective
Provider Name:
Provider #:
Current/Prospective
Provider Address:
I certify that I have reviewed the most current CORI provided by the California Department of Justice,
and/or court records/documentation provided by a Federal, State or County government agency to
make the determination that the above referenced current/prospective provider does not currently
have an IHSS exclusionary conviction. I certify that the above referenced current/prospective provider
has completed all requirements of the IHSS provider enrollment process set forth in the Manual of
Policies and Procedures, Section 30 776 et. seq., and therefore, is currently eligible for enrollment as
an IHSS provider without any restrictions. I have determined that the CORI details currently entered in
CMIPS for the above referenced current/prospective provider are no longer valid and request removal
of the CORI details from CMIPS in order to proceed with the IHSS provider enrollment process or to
update a current provider’s eligibility status.
SEND ENCRYPTED E-MAIL WITH COMPLETED FORM TO THE ADULT PROGRAMS DIVISION,
APPEALS AND ADMINISTRATIVE REVIEW UNIT AT IHSSCORIremovals@dss.ca.gov.
MY SIGNATURE CERTIFIES THAT THE ABOVE STATEMENTS ARE TRUE AND CORRECT.
THE COUNTY/PUBLIC AUTHORITY ASSUMES ALL LIABILITY IN THE REVIEW OF THE CORI,
COURT RECORDS/DOCUMENTATION AND CMIPS IN DETERMINING THAT THE ABOVE
REFERENCED CURRENT/PROSPECTIVE PROVIDER DOES NOT HAVE AN EXCLUSIONARY
CONVICTION AND IS CURRENTLY ELIGIBLE FOR ENROLLMENT AS AN IHSS PROVIDER
WITHOUT ANY RESTRICTIONS.
Signature:
Date:
Printed Name:
Telephone #:
County/PA Agency Name:
Mailing Address:
E-Mail Address:
SOC 2324 (1/19)
Page 1 of 1
State of California – Health and Human Services Agency
California Department of Social Services
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)
THIS FORM IS FOR COUNTY/PUBLIC AUTHORITY USE ONLY
County:
Current/Prospective
Current/Prospective
Provider Name:
Provider #:
Current/Prospective
Provider Address:
I certify that I have reviewed the most current CORI provided by the California Department of Justice,
and/or court records/documentation provided by a Federal, State or County government agency to
make the determination that the above referenced current/prospective provider does not currently
have an IHSS exclusionary conviction. I certify that the above referenced current/prospective provider
has completed all requirements of the IHSS provider enrollment process set forth in the Manual of
Policies and Procedures, Section 30 776 et. seq., and therefore, is currently eligible for enrollment as
an IHSS provider without any restrictions. I have determined that the CORI details currently entered in
CMIPS for the above referenced current/prospective provider are no longer valid and request removal
of the CORI details from CMIPS in order to proceed with the IHSS provider enrollment process or to
update a current provider’s eligibility status.
SEND ENCRYPTED E-MAIL WITH COMPLETED FORM TO THE ADULT PROGRAMS DIVISION,
APPEALS AND ADMINISTRATIVE REVIEW UNIT AT IHSSCORIremovals@dss.ca.gov.
MY SIGNATURE CERTIFIES THAT THE ABOVE STATEMENTS ARE TRUE AND CORRECT.
THE COUNTY/PUBLIC AUTHORITY ASSUMES ALL LIABILITY IN THE REVIEW OF THE CORI,
COURT RECORDS/DOCUMENTATION AND CMIPS IN DETERMINING THAT THE ABOVE
REFERENCED CURRENT/PROSPECTIVE PROVIDER DOES NOT HAVE AN EXCLUSIONARY
CONVICTION AND IS CURRENTLY ELIGIBLE FOR ENROLLMENT AS AN IHSS PROVIDER
WITHOUT ANY RESTRICTIONS.
Signature:
Date:
Printed Name:
Telephone #:
County/PA Agency Name:
Mailing Address:
E-Mail Address:
SOC 2324 (1/19)
Page 1 of 1