IHSS - IRS Live-In Self-Certification Form for Federal and State Tax Wage Exclusion

Sep 19, 2026

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Live-in self-certification form for IHSS and WPCS providers in California, used to certify that eligible wages paid for providing in-home personal care services to the named recipient will be excluded from federal and state personal income taxes. Includes sections to record provider and recipient identifying information, county of residence, provider signature, and signature date. Provides clear English-only completion instructions, required pen type, formatting requirements, and where to find provider number and recipient case number on IHSS paperwork. Return instructions list the IRS live-in submission address in West Sacramento, CA.

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Provider Self-Certification

Required Information

Instructions for Filling Out the Form

Return Address

FAQs

What does this IHSS/WPCS live-in self-certification form certify?

By completing the form, the provider certifies that wages received for providing IHSS and/or WPCS services to the named recipient will be excluded from federal and state personal income taxes.

What information must be completed on the form?

Provider name, provider number, recipient name, recipient case number, and county of residence must be completed, along with the provider signature and date of signature.

What are the key instructions for completing the form correctly?

Enter all requested information in English, sign and date the designated lines, use black ink and print clearly, and do not wrinkle or staple the form.

Sep 19, 2026

Upload by Cipher