Form SOC2298 "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" - California

What Is Form SOC2298?

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 December 1, 2016;
  • 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 SOC2298 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 SOC2298 "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" - California

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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 IN ENGLISH.
SEE PAGE 2 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.
Under penalties of perjury, I declare that I am a provider receiving payments under the
IHSS and/or WPCS programs for care I provide to ____________________________,
who lives with me in the same home.
Provider Signature:
Date of Signature:
RETURN COMPLETED FORM TO:
IHSS – IRS Live-In Self-Certification
P.O. Box 1677
West Sacramento, CA 95691-6677
SOC 2298 (1/19)
Page 1 of 2
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 IN ENGLISH.
SEE PAGE 2 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.
Under penalties of perjury, I declare that I am a provider receiving payments under the
IHSS and/or WPCS programs for care I provide to ____________________________,
who lives with me in the same home.
Provider Signature:
Date of Signature:
RETURN COMPLETED FORM TO:
IHSS – IRS Live-In Self-Certification
P.O. Box 1677
West Sacramento, CA 95691-6677
SOC 2298 (1/19)
Page 1 of 2
State of California – Health and Human Services Agency
California Department of Social Services
Instructions for filling out the Live-In Self-Certification Form
1. All requested information must be entered in English on the form in the designated
area.
2. You must sign the form on the designated line.
3. You must provide the date the form was signed on the designed line.
4. Only use black ink and please print clearly.
5. Do not wrinkle or staple the form.
6. Provider Name: Enter your name as it appears on your IHSS paperwork.
7. Provider Number: May be found on your IHSS paperwork – (Provider Notification
of Recipient Authorized Hours and Services and Maximum Weekly Hours, Provider
Timesheet, etc.).
8. Recipient Case Number: May be found on your IHSS paperwork – Provider
Notification of Recipient Authorized Hours and Services and Maximum Weekly
Hours, Provider Timesheet, etc.
9. Recipient County of Residence: Please enter the county where you and your
Recipient reside.
SOC 2298 (1/19)
Page 2 of 2
Page of 2