California Form Soc 295 – Fill Out and Use This PDF

Enter the Date of Application and the Case Number (if known).

Enter the Name of Applicant and Social Security Number.

Retain your copy of your completed application. Regarding your Social Security Number, it is mandatory that you provide your Social Security Number(s) as required in 42 USC 405, or that you apply for a Social Security Number(s) with the Social Security Administration. This information will be used in eligibility determination and coordinating information with other public agencies.

Enter the Street Address, City, State, Zip Code, Telephone and Email.

Enter the Date of Birth and mark Sex: Male or Female.

Section 2, Sexual Orientation and Gender Identity (Optional): providing responses is optional and confidential. Any information you provide in this section will not be used in your eligibility determination.

For What is your gender identity?, check the box that best describes your current gender identity: Female, Male, Transgender: male to female, Transgender: female to male, Non-Binary (neither male nor female), Another gender identity or Decline to state.

For What sex was listed on your original birth certificate?, mark Female or Male.

To answer How do you describe your sexual orientation?, select one answer: Straight/heterosexual, Gay or lesbian, Bisexual, Queer, Another sexual orientation, Unknown or Decline to state.

Mark Yes or No for Are you a Veteran? and Yes or No for Are you a Spouse/Child of a Veteran? If YES, give Veteran name and Claim Number.

Mark Yes or No for Do you receive SSI/SSP benefits? If yes, check your type of living arrangement: Independent Living, Board and Care or Home of Another.

Enter the Services being requested.

Mark Yes or No for Have you received In-Home Supportive Services (IHSS) in the past? If Yes, complete Date and county where service was last received, Total Monthly Hours and Name Used (if different from the Name of Applicant).

Under List Household Members, enter the Name of Spouse with Birthdate and Social Security Number.

Under List Household Members, enter the Name of: Parent, Child, Other Relative or Non-Relative, with Birthdate and Social Security Number.

Section 7 - Ethnic and Language Information. The law requires that information on ethnic origin and primary language be collected. If you do not complete this section, social service staff will make a determination. The information will not affect your eligibility for service.

A. My Ethnic Origin is: choose one (See Page 8 for a list of Ethnicities and Codes). B1. What language do you prefer to read? Please choose one.

Ethnic Codes: A. White. B. Hispanic. C. Black. D. Other Asian or Pacific Islander. E. American Indian or Alaskan Native. F. Filipino. G. Chinese. H. Cambodian. I. Japanese. J. Korean. K. Samoan. L. Asian Indian. M. Hawaiian. N. Guamanian. O. Laotian. P. Vietnamese. Q. Other. R. Mixed Ethnicity.

B2. What language do you prefer to speak? Please choose one from the list of Languages and Codes on Page 8.

To accommodate blind or visually-impaired applicants, IHSS information is available in the following alternative formats. Please indicate which format you would prefer, if applicable. Providing information in this section will not affect your eligibility for services.

Mark Yes or No for I am Blind. If yes, please choose one of the following for each of the three types of Department of Social Services (DSS) documents listed.

Mark Yes or No for I am Visually Impaired.

Section 9 - Affirmation. I affirm that the information in Section 1 - Personal Information to Section 8 - Communication Accommodations is true to the best of my knowledge and belief. I agree to cooperate fully if verification of the statements in those sections is required in the future.

I also understand that as the employer of my IHSS provider(s) I am responsible for: Hiring, training, supervising, scheduling and, when necessary, firing my provider(s). Ensuring the total hours reported by all providers who work for me do not exceed my IHSS authorized hours each month. Referring any individual I want to hire to the County IHSS office to complete the provider eligibility process. Notifying the County IHSS office within 10 days when I hire or fire a provider.

I understand and agree to the following terms and limitations regarding payment for services by the IHSS program: In order for any individual to be paid by the IHSS program, they must be approved as an IHSS eligible provider. If I choose to have an individual work for me who has not yet been approved as an eligible IHSS provider, I will be responsible for paying him/her if he/she is not approved. The IHSS program will not pay for any services provided to me until my application for services is approved and then will only pay for those services that are authorized for me to receive by the IHSS Program. I will be responsible for paying for any services I receive that are not included in my IHSS authorization. I will be responsible for paying my Share-of-Cost (SOC) and informing my individual provider(s) of that SOC.

As a part of my eligibility for IHSS I also understand and agree to cooperate with the following: To promote program integrity and quality assurance, I may be subject to (un)announced visits to my home and that I or my provider(s) may receive letters identifying program requirement concerns from the State Department of Health Care Services (DHCS), California Department of Social Services (CDSS) and/or the County in which I receive services.

The purpose of the visits and letters is to ensure that program requirements are being followed and that the authorized services are necessary for you to remain safely in your home. The visit will also verify that the authorized services are being provided, that the quality of those services is acceptable, and that your well-being is protected.

If it is found that IHSS services are not required or not being properly provided, you and/or your provider may be subject to a Medi-Cal fraud investigation. If fraud is substantiated, you and/or your provider will be prosecuted for Medi-Cal fraud.

Sign Signature of Applicant and enter the Date.

Only if applicable, the Applicant's Representative signs Signature of Applicant's Representative with the Date, and enters the Representative's Relationship to Applicant, Telephone Number and Address.

Application for In-Home Supportive Services, California Department of Social Services. All sections of this form must be completed. Information provided is subject to verification.