Form Na 1255 - Notice Of Action - In-Home Supportive Services (Ihss) Termination
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1NOTICE OF ACTION
STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
COUNTY OF
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES (IHSS)
TERMINATION
Notice Date :
Case Name :
Case Number :
NOTE: This notice relates ONLY to your In-Home Supportive
Social Worker Name :
Services. It does NOT affect your receipt of SSI/SSP, Social
Social Worker Number :
Security, or Medi-Cal.
KEEP THIS NOTICE WITH YOUR
Social Worker Telephone :
IMPORTANT PAPERS.
Social Worker Address :
(ADDRESSEE)
Your eligibility for the In-Home for Supportive Services will stop as of __________________. Here’s why:
MMDDYYYY
Rules: The rules noted above in parentheses apply; you may review the Manual of Policy and Procedures
(MPP) at your local IHSS office.
Questions?: Please contact your IHSS social worker.
State Hearing: If you think this action is wrong, you can ask for a hearing. The back of this page tells how.
NA 1255 (5/09) - IHSS TERMINATION
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