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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.",{"@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/ihss-irs-live-in-self-certification-form-for-federal-and-state-tax-wage-exclusion/304720/",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/ihss-irs-live-in-self-certification-form-for-federal-and-state-tax-wage-exclusion/304720.png","ImageObject",442,249,{"name":88,"@type":89},"Cipher","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-29","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},"What does this IHSS/WPCS live-in self-certification form certify?","Question",{"text":109,"@type":110},"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.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What information must be completed on the form?",{"text":114,"@type":110},"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.",{"name":116,"@type":107,"acceptedAnswer":117},"What are the key instructions for completing the form correctly?",{"text":118,"@type":110},"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.","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},304720,1790484834,{"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":73,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":9},687208528416,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","State of California – Health and Human Services Agency California Department of Social Services  \nIN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM AND WAIVER PERSONAL CARE SERVICES (WPCS) PROGRAM LIVE-IN SELF-CERTIFICATION FORM FOR FEDERAL AND STATE TAX WAGE EXCLUSION  \n\n| Provider Name | Recipient Name |\n| --- | --- |\n| Provider Number | Recipient Case Number |\n\nCounty Of Residence  \nALL INFORMATION MUST BE COMPLETED IN ENGLISH.  \nSEE PAGE 2 FOR INSTRUCTIONS.  \nProvider Self-Certification  \nBy 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.  \nUnder 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.  \n\n| Provider Signature: | Date of Signature: |\n| --- | --- |\n\nRETURN COMPLETED FORM TO:  \nIHSS – IRS Live-In Self-Certification  \nP.O. Box 1677  \nWest Sacramento, CA 95691-6677  \nInstructions for filling out the Live-In Self-Certification Form  \n1. All requested information must be entered in English on the form in the designated area.  \n2. You must sign the form on the designated line.  \n3. You must provide the date the form was signed on the designed line.  \n4. Only use black ink and please print clearly.  \n5. Do not wrinkle or staple the form.  \n6. Provider Name: Enter your name as it appears on your IHSS paperwork.  \n7. Provider Number: May be found on your IHSS paperwork –(Provider Notification of Recipient Authorized Hours and Services and Maximum Weekly Hours, Provider Timesheet, etc. ) .  \n8. 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.  \n9. Recipient County of Residence: Please enter the county where you and your Recipient reside.","cbCaimjJPoMyoWWi","https://ap.wps.com/l/cbCaimjJPoMyoWWi","pdf",693594,"English","# Provider Self-Certification\n## Required Information\n## Instructions for Filling Out the Form\n## Return Address","[{\"question\":\"What does this IHSS/WPCS live-in self-certification form certify?\",\"answer\":\"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.\"},{\"question\":\"What information must be completed on the form?\",\"answer\":\"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.\"},{\"question\":\"What are the key instructions for completing the form correctly?\",\"answer\":\"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.\"}]","IHSS - IRS Live-In Self-Certification Form for Federal and State Tax Wage Exclusion | PDF",1789816521]