Get Voucher Program Eligibility Verification Form

Completing the Voucher Program Eligibility Verification Form is a vital step in ensuring that individuals receive appropriate resources and support. This guide will help you navigate the form efficiently and confidently, providing clear instructions for each section.

Follow the steps to complete the form online effectively.

1. Press the ‘Get Form’ button to access the form and open it for editing.
2. Begin by entering the Customer’s Name and Date of Birth in the designated fields.
3. Answer the question regarding residence in St. Louis County by selecting either ‘Yes’ or ‘No’.
4. Indicate whether the St. Louis Regional Center has determined the individual has a developmental disability by selecting ‘Yes’ or ‘No’.
5. Select the appropriate diagnosis from the provided list. If applicable, check the box for Other and specify the diagnosis.
6. If you selected Other, indicate any substantial functional limitations in two or more provided areas.
7. State when the customer’s disability manifested: either prior to age 19 or age 22.
8. Describe the required supervision/care level by selecting one of the options provided.
9. Choose the Current Residence Type from the list of options available.
10. Confirm if the Customer’s Date of Birth is correct, providing a corrected date if necessary.
11. Enter the Customer’s Social Security Number into the designated fields.
12. Indicate the Customer’s gender by checking either Male or Female.
13. Fill in the DMH Case Number if applicable.
14. Note if you are aware of other funding sources that may assist the customer; if yes, list them.
15. Provide your signature, date, printed name, agency information, title, phone number, and address in the designated spaces.
16. Once all fields are filled out, you may save your changes, download, print, or share the form.

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