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2. IHSS Recipient Information
   Please provide as much information as possible. Only the pink boxes are required.
4. IHSS Recipient First Name*
5. IHSS Recipient Last Name*
7. IHSS Recipient Phone Number
8. IHSS Recipient Email Address
9. IHSS Recipient Case Number
11. How would the recipient like to receive the list?

    1. Email
    2. Mail
    3. Both
13. Does the recipient need any accommodations to make the list more accessible? (Optional)

    1. Large Font Paper List
    2. Formatted for Screen Reader
15. Information of the Individual Submitting the List Request

    Anyone is welcome to submit a list on behalf of a Recipient. 

    To receive a copy of the list, a signed 'Release of Information' form or an 'Authorized Representative' form must be on file. For more information, please call (707) 259-8359.

17. First Name*
18. Last Name*
20. Email Address*
    Please write 'none' if you do not have an email address.
21. Phone Number
23. Notes (Optional)
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25. Submit

* indicates a required field