Forms
Provider Enrollment Forms:
Email to: [email protected] ORMail to: 500 Ellinwood Way, Ste. 110, Pleasant Hill, CA 94523
Other Provider Forms:
W-4
Federal Income Tax withholding
Must be mailed to:
IHSS – PAYROLL
400 Ellinwood Way
Pleasant Hill, CA 04523
DE-4
State Income Tax withholding (only required if withholding differs from your federal withholding amount)
Must be mailed to:
IHSS – PAYROLL
400 Ellinwood Way
Pleasant Hill, CA 04523
SOC 2298
Live-in Certification form – By completing this form, the provider certifies that the wages received for providing IHSS and/or WPCS services to the recipient who lives in the home with the provider will be excluded from federal and state personal income taxes
Must be mailed to:
IHSS – IRS Live-In Self-Certification
P.O. BOX 1677
West Sacramento, CA 95691-6677
SOC 840
Change of address form
Email to: [email protected] OR
Mail to: 500 Ellinwood Way, Ste. 110, Pleasant Hill, CA 94523