Form Soc 432 - Claim For Reimbursement - In-Home Supportive Services Program - Contract Expenditures
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2STATE OF CALIFORNIA — HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CLAIM FOR REIMBURSEMENT
FROM:
IN-HOME SUPPORTIVE SERVICES PROGRAM
COUNTY:
CONTRACT EXPENDITURES
ADDRESS:
To: Adult Programs Branch
California Department of Social Services
744 P Street, MS 19-96
Sacramento, CA 95814
CONTACT PERSON:
PHONE NUMBER:
(
)
CONTRACT NUMBER
CONTRACTOR NAME
SERVICE MONTH/YEAR
WARRANT DATE__________________________
CONTRACT SERVICE DELIVERY TOTALS FOR MONTH BY FUNDING SOURCE:
FISCAL YEAR/QTR. _______________________
FUNDING SOURCE
TOTAL CASES
TOTAL HOURS
GROSS EXP.
*ADJUSTMENTS
TOTAL NET EXP.
PCSP
____________
_____________
_____________
_____________
____________
IPW
____________
_____________
_____________
_____________
____________
IHSS
____________
_____________
_____________
_____________
____________
Totals
____________
_____________
_____________
_____________
____________
*
If the actual PCSP, IPW, and IHSS adjustment amounts are not known, please estimate the PCSP, IPW, and IHSS
amounts based on the PCSP, IPW, and IHSS hours to total hours ratio.
COST REIMBURSEMENT DETAIL BY FUNDING SOURCE:
FUNDING
FEDERAL
STATE/COUNTY
STATE
COUNTY
TOTAL NET
SOURCE
EXPENDITURE
PCSP
(50%) ________________
(50%) ________________
(65%) ________________
(35%) ________________
______________
IPW
(50%) ________________
(50%) ________________
(65%) ________________
(35%) ________________
______________
IHSS
________________
________________
(65%) ________________
(35%) ________________
______________
Totals
________________
________________
________________
________________
______________
I hereby certify, under penalty of perjury, that I am the official
I hereby certify under penalty of perjury, that I am the official
responsible for the administration of the Personal Care Services
responsible for the examination and settlement of accounts, that I
Program; that I have not violated any of the provisions of federal
have not violated any provisions of federal law (Section
law (Section 440.170(f) of Title 42 of the Code of Federal
440.170(f) of Title 42 of the Code of Federal Regulations)
Regulations) Personal Care as a benefit; Section 14132.95 & .951
Personal Care as a benefit; Section 14132.95 & .951 Welfare and
Welfare and Institutions Code personal care services as a benefit
Institutions Code personal care services as a benefit for the
for the medically needy and categorically eligible; and the
medically needy and categorically eligible; and the provisions of
provisions of Section 1090 to 1096, inclusive of the Government
Sections 1070 to 1096, inclusive, of the Government Code; that
Codes; that the amounts claimed herein are properly claimable as
the expenditures claimed herein have been authorized, that a
expenditures for the administration of the project as specified in
clearly delineated audit trail is in place to substantiate said
accordance with all provisions of the Welfare and Institutions
expenditures, and that payments therefore have been made or
Codes, the rules and regulations of the State Benefits and
expenditures otherwise incurred according to law.
Services Advisory Board.
SIGNATURE OF COUNTY WELFARE DIRECTOR OR CONTRACT ADMINISTRATOR DATE
SIGNATURE OF COUNTY AUDITOR OR CONTROLLER
DATE
Approved by: __________________________________________ Date:________________________
(State IHSS Program Manager)
SOC 432 (8/04)
PAGE 1 OF 2
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