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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 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.  \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\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\n\n| What sex was listed on your original birth certificate? 􀂉 Female 􀂉 Male |  |\n| --- | --- |\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\u003Cbr>􀂅 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?\u003Cbr>􀂉 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\nSection 5 – Past IHSS Information  \n\n| Have you received In-Home Supportive Services (IHSS) in the past?\u003Cbr>􀂉 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\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 8 for a list of Ethnicities and Codes)\u003Cbr>Please choose one | B1 . What language do you prefer to read?\u003Cbr>B2 . What language do you prefer to speak?\u003Cbr>( Please choose one from the list of Languages and Codes on Page 8)\u003Cbr>Please choose one\u003Cbr>Please choose one |\n| --- | --- |\n\nSOC 295 (9/18) Page 3 of 8  \nSection 8 – Communication Accommodations  \nTo accommodate blind or visually-impaired applicants, IHSS information is available in the following alternative formats. Please","cbCaioVqZSgTGuYj","https://ap.wps.com/l/cbCaioVqZSgTGuYj","pdf",331906,8,"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\n# Section 9 - Affirmation","[{\"question\":\"What information must the applicant provide on this application?\",\"answer\":\"The form requires completion of all sections, including personal information, household members, and service-related history. It also requests SSI/SSP details and ethnic and language information, plus optional disclosures where applicable.\"},{\"question\":\"Why does the form ask for a Social Security Number?\",\"answer\":\"The Social Security Number is mandatory as required by 42 USC 405 or requires applying for one through the Social Security Administration. The information is used for eligibility determination and coordination with other public agencies.\"},{\"question\":\"Is providing sexual orientation and gender identity information mandatory?\",\"answer\":\"No. Responses in that section are optional and confidential, and information provided there is not used in the eligibility determination.\"},{\"question\":\"What communication accommodations are available for blind or visually impaired applicants?\",\"answer\":\"The form offers alternative formats such as braille documents, audio CD, data CD, or county support for different DSS document types. It also includes options for timesheets, including telephonic and electronic timesheet system choices.\"}]","California Department of Social Services - Application for In-Home Supportive Services | PDF",1789824112]