IHSS SPECIAL TRANSACTION TIME SHEET RECIPIENT NUMBER PROVIDER NUMBER

IHSS SPECIAL TRANSACTION TIME SHEET RECIPIENT NUMBER PROVIDER NUMBER

DESCARGAR PDF

IHSS SPECIAL TRANSACTION TIME SHEET
RECIPIENT NUMBER: PROVIDER NUMBER:
Last Name
First
Ml
Last Name
First
MI
Address
Address
City
State
Zip
City
State
Zip
You are authorized: Hours for this SPEC transaction for the Month of:
DAY
1
2
3
4
5
6
7
8
HOURS/MINS
 
 
DAY
9
10
11
12
13
14
15
 
HOURS/MINS
 
 
 
 
 
 
 
 
 
 
 
 
 
 
WE AFFIRM THAT THIS TIMESHEET IS A TRUE AND CORRECT STATEMENT OF TIME
WORKED THE IHSS PROGRAM AND THE SHARE OF COST LIABILITY ________
FOR THE PERIOD HAS BEEN MET (SIGN ONLY AFTER WORK HAS BEEN COMPLETED).
AFIRMAMOS QUE ESTE 1-IORARJO ES CUENTA CORRECTA DE 1-IORAS TRABAJADAS
BAJO EL PROGRAMA DE II-ISS Y QUE LA PARTE DEL COSTO QUE PAGAMOS
NOSOTROS POR ESTE PERIODO Y A ESTA PAGADA (FIRME SOLAMENTE CUANDO EL
TRABAJO ESTE COMPLETADO) Freeform 5 RECIPIENT SIGNATURE: DATE:
PROVIDER SIGNATURE: DATE:
X X______________________________________
_________________________________________________________________________________________________________________
IHSS SPECIAL TRANSACTION TIME SHEET
RECIPIENT NUMBER: PROVIDER NUMBER:
Last Name
First
Ml
Last Name
First
MI
Address
Address
City
State
Zip
City
State
Zip
You are authorized: Hours for this SPEC transaction for the Month of:
DAY
16
17
18
19
20
21
22
23
HOURS/MINS
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DAY
24
25
26
27
28
29
30
31
HOURS/MINS
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
WE AFFIRM THAT THIS TIMESHEET IS A TRUE AND CORRECT STATEMENT OF TIME
WORKED THE IHSS PROGRAM AND THE SHARE OF COST LIABILITY ________
FOR THE PERIOD HAS BEEN MET (SIGN ONLY AFTER WORK HAS BEEN COMPLETED).
AFIRMAMOS QUE ESTE 1-IORARJO ES CUENTA CORRECTA DE 1-IORAS TRABAJADAS
BAJO EL PROGRAMA DE II-ISS Y QUE LA PARTE DEL COSTO QUE PAGAMOS
NOSOTROS POR ESTE PERIODO Y A ESTA PAGADA (FIRME SOLAMENTE CUANDO EL
TRABAJO ESTE COMPLETADO) Freeform 5 RECIPIENT SIGNATURE: DATE:
PROVIDER SIGNATURE: DATE:
X X ____________________________________