[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-306394-105":53,"doc-detail-306394-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","application-for-in-home-supportive-services-soc-295l-section-form","APPLICATION FOR IN-HOME SUPPORTIVE SERVICES - SOC 295L - Section Form","","Application form for In-Home Supportive Services from the State of California, Health and Human Services Agency, California Department of Social Services. Collects applicant identification details, Social Security Number information for eligibility verification, and optional Sexual Orientation and Gender Identity questions. Includes Veteran status, SSI/SSP benefit information, past IHSS history, household member listing, ethnic origin and preferred language, and optional communication accommodation selections for blind or visually impaired applicants.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/application-for-in-home-supportive-services-soc-295l-section-form/306394/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/application-for-in-home-supportive-services-soc-295l-section-form/306394.png","ImageObject",442,249,{"name":88,"@type":89},"Anna Hans","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-22","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",6,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"Is Social Security Number information required on this application?","Question",{"text":109,"@type":110},"Yes. The form states it is mandatory to provide the Social Security Number(s) as required by 42 USC 405, or to apply for an SSN with the Social Security Administration.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"Which parts of the form are optional and confidential?",{"text":114,"@type":110},"Section 2 (Sexual Orientation and Gender Identity) is optional and confidential. The form also states that providing information in this section will not be used for eligibility determination.",{"name":116,"@type":107,"acceptedAnswer":117},"How does the application address communication accommodations for blind or visually impaired applicants?",{"text":118,"@type":110},"Section 8 allows applicants to indicate whether they are blind or visually impaired and to choose preferred alternative formats for specific Department of Social Services document types.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},306394,1790186887,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":136,"language":137,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":138,"faqs":139,"seo_title":140,"seo_description":61,"update_tm":141,"read_time":76},5909892332657,"https://ap-avatar.wpscdn.com/davatar_994ba38a5ba835b3df7d355c54d3ed8d","State of California – Health and Human Services Agency California Department of Social Services  \nAPPLICATION FOR IN-HOME SUPPORTIVE SERVICES  To the Applicant: All sections of this form must be completed. Information provided is subject to verification.  \nNOTE: Retain your copy of your completed application. Regarding your Social Security Number, it is mandatory that you provide  \nyour 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.  \n\n| Date of Application: | Case Number (if known): |\n| --- | --- |\n\nSection 1 – Personal Information  \n\n| Name of Applicant: |  |  | Social Security Number: |  |\n| --- | --- | --- | --- | --- |\n| Street Address: |  |  |  | City: |\n| State: | Zip Code: | Telephone: |  |  |\n|  |  | Email: |  |  |\n| Date of Birth: |  | Sex:  Male  Female |  |  |\n\nState of California – Health and Human Services Agency California Department of Social Services   \nSection 2 – Sexual Orientation and Gender Identity (Optional)  \nProviding responses in the sections below is optional and confidential. Any information you provide in this section will not be used in your eligibility determination.  \n\n| What is your gender identity?\u003Cbr>(check the box that best describes your current gender identity) |  |\n| --- | --- |\n| 􀂅Female\u003Cbr>􀂅Male\u003Cbr>􀂅Transgender: male to female\u003Cbr>􀂅Transgender: female to male | 􀂅Non-Binary (neither male nor female)\u003Cbr>􀂅Another gender identity\u003Cbr>􀂅Decline to state |\n| What sex was listed on your original birth certificate?\u003Cbr> Female  Male |  |\n| How do you describe your sexual orientation?\u003Cbr>Select one answer. |  |\n| 􀂅Straight/heterosexual\u003Cbr>􀂅Gay or lesbian\u003Cbr>􀂅Bisexual\u003Cbr>􀂅Queer | 􀂅Another sexual orientation 􀂅Unknown\u003Cbr>􀂅Decline to state |\n\nSection 3 – Veteran Information  \n\n| Are you a Veteran?\u003Cbr> Yes  No | Are you a Spouse/Child of a Veteran?  Yes  No |\n| --- | --- |\n| If YES, give Veteran name and Claim Number: |  |\n\nSection 4 – SSI/SSP Information  \n\n| Do you receive SSI/SSP benefits? |  | Yes |  | No |\n| --- | --- | --- | --- | --- |\n| If yes, check your type of living arrangement:\u003Cbr> Independent Living  Board and Care  Home of Another |  |  |  |  |\n| Services being requested: |  |  |  |  |\n\nSOC 295L (9/18) Page 2 of 9  \nState of California – Health and Human Services Agency California Department of Social Services  \nSection 5 – Past IHSS Information  \n\n| Have you received In-Home Supportive Services (IHSS) in the past?  Yes  No |  |\n| --- | --- |\n| If Yes, complete the following.\u003Cbr>Date and county where service was last received: |  |\n| Total Monthly Hours: | Name Used (if different from above): |\n\nSection 6 – Household Information  \nList Household Members:  \n\n| Name of Spouse: |  |\n| --- | --- |\n| Birthdate: | Social Security Number: |\n| Name of:  Parent  Child  Other Relative  Non-Relative |  |\n| Birthdate: | Social Security Number: |\n| Name of:  Parent  Child  Other Relative  Non-Relative |  |\n| Birthdate: | Social Security Number: |\n| Name of:  Parent  Child  Other Relative  Non-Relative |  |\n| Birthdate: | Social Security Number: |\n| Name of:  Parent  Child  Other Relative  Non-Relative |  |\n| Birthdate: | Social Security Number: |\n| Name of:  Parent  Child  Other Relative  Non-Relative |  |\n| Birthdate: | Social Security Number: |\n\nSOC 295L (9/18) Page 3 of 9  \nState of California – Health and Human Services Agency California Department of Social Services   \nSection 7 – Ethnic and Language Information  \nThe 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.  \n\n| A. My Ethnic Origin is:\u003Cbr>(See Page 9 for a list of Ethnicities and Codes)\u003Cbr>Please choose one | B1 . What language do you prefer to read?\u003Cbr","cbCaiqSuMEm4HZZq","https://ap.wps.com/l/cbCaiqSuMEm4HZZq","pdf",918412,9,"English","# Section 1 – Personal Information\n# Section 2 – Sexual Orientation and Gender Identity (Optional)\n# Section 3 – Veteran Information\n# Section 4 – SSI/SSP Information\n# Section 5 – Past IHSS Information\n# Section 6 – Household Information\n# Section 7 – Ethnic and Language Information\n# Section 8 – Communication Accommodations","[{\"question\":\"Is Social Security Number information required on this application?\",\"answer\":\"Yes. The form states it is mandatory to provide the Social Security Number(s) as required by 42 USC 405, or to apply for an SSN with the Social Security Administration.\"},{\"question\":\"Which parts of the form are optional and confidential?\",\"answer\":\"Section 2 (Sexual Orientation and Gender Identity) is optional and confidential. The form also states that providing information in this section will not be used for eligibility determination.\"},{\"question\":\"How does the application address communication accommodations for blind or visually impaired applicants?\",\"answer\":\"Section 8 allows applicants to indicate whether they are blind or visually impaired and to choose preferred alternative formats for specific Department of Social Services document types.\"}]","APPLICATION FOR IN-HOME SUPPORTIVE SERVICES - SOC 295L - Section Form | PDF",1789836029]