STATE OF CALIFORNIA - HEALTH AN HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES
Recipient/Employer Responsibility Checklist
I, _________________________________________________ , HAVE BEEN INFORMED BY MY SOCIAL WORKER THAT AS A
RECIPIENT/EMPLOYER, I AM RESPONSIBLE FOR THE ACTIVITIES LISTED BELOW.
1) Provide required documentation to my Social Worker to determine continued eligibility and need for services. Information to
report includes, but is not limited to, changes to my income, household composition, marital status, property ownership, phone
number, and time I am away from my home.
2) Find, hire, train, supervise, and fire the provider I employ.
3) Comply with laws and regulations relating to wages/hours/working conditions and hiring of persons under age 18.
NOTE: Refer to Industrial Welfare Commission (IWC) Order Number 15 regarding wages/hours/working conditions obtainable
from the State Department of Industrial Relations, Division of Labor Standards and Enforcement listed in the telephone
book. Additional information regarding the hiring of minors may be obtained by contacting your local school district.
4) Verify that my provider legally resides in the United States. My provider and I will complete Form I-9. I will retain the I-9 for at
least three (3) years or one (1) year after employment ends, which ever is longer. I will protect the provider’s confidential
information, such as his/her social security number, address, and phone number.
5) Ensure standards of compensation, work scheduling and working conditions for my provider.
6) Inform my Social Worker of any future change in my provider(s), including:
__ Name
__ Address
__ Telephone Number
__ Relationship to me, if any
__ Hours to be worked and services to be performed by each provider
7) Inform my provider that the gross hourly rate of pay is $______________________, and that Social Security and State
Disability Insurance taxes are deducted from the provider’s wages.
8) Inform my provider that he/she may request that Federal and/or State income taxes be deducted from his/her wages. Instruct
the provider to submit Form W-4 (for federal income tax withholding) and/or Form DE 4 (for state income tax withholding).
9) Inform my provider that he/she is covered by Workers' Compensation, State Unemployment Insurance benefits, and State
Disability Insurance benefits.
10) Inform my provider that he/she will receive an information sheet that will state my authorized services and the authorized time
given to perform those services. Inform the provider that he/she is not paid to perform work when I am away from my home
(for example, when in a hospital or away on vacation).
11) Pay my share of cost, if any.
12) Verify and sign my provider’s timesheet for each pay period, showing the correct day(s) and the total number of hours worked.
I understand I can be prosecuted under Federal and State laws for reporting false information or concealing information. I
understand that when required, it will be necessary for me to place my fingerprint on my provider’s timehsheet to verify the
correct day(s) and hours worked. This will be necessary, so my provider can be paid.
13) Ensure my provider signed his/her timesheet.
14) Advise my provider to mail his/her signed timesheet to the appropriate address at the end
of each pay period.
Recipient’ Signature
Date
Printed Name
SOC 332 (9/09)
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