Form Hcs 101 - Home Care Aide Registration Renewal
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1State of California – Health and Human Services Agency
California Department of Social Services
HOME CARE AIDE REGISTRATION RENEWAL
Please type or print clearly. Please ensure that you include a check or money order in the amount of $35.00
payable to the California Department of Social Services. Mail this completed application and a check or money
order to: The California Department of Social Services, Home Care Services Bureau, 744 P Street, MS T8-
3-90, Sacramento, CA 95814. Your renewal application and fee must be postmarked on or before your
expiration date or your registration will be forfeited.
Name (Last, First, Middle):
Per ID#:
I wish to renew my home care aide registration. I have included my $35.00 renewal fee
by check or money order.
I do not wish to renew my home care aide registration. I hereby relinquish my
registration. The relinquishment date will reflect the date this letter is received by the
Home Care Services Bureau (if postmarked on or before my expiration date).
If your address, email address, or telephone numbers have changed, please update your information below:
RESIDENCE ADDRESS:
Street Address:
Apt:
City:
State:
Zip Code:
County:
MAILING ADDRESS (If different than above):
P.O. Box/Street Address:
Apt:
City:
State:
Zip Code:
County:
E-MAIL (Voluntary):
TELEPHONE NUMBERS:
Day:
Evening:
If you
need to change your name, you must submit a Home Care Aide Registry Request for Name/Address
Ch
ange (HCS 105) to the address listed above. You can obtain this form at:
entres/forms/English/HCS105.pdf.
Please note, you are required to notify the Department of Social Services within ten (10) days of an address
change or your registration may be forfeited.
I declare under penalty of perjury that the statements on this form are correct to the best of
my knowledge.
Signature:
Date:
HCS 101 (10/17)
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