Follow the steps to successfully complete the application.

1. Click ‘Get Form’ button to access the application and open it in your preferred online editing tool.
2. Begin by filling in the individual information section with accurate details. Provide the name, social security number, recipient identification number, date of birth, gender, and answer if the individual is ambulatory.
3. Proceed to the ICAP or SIBR scores section. Enter the summary score and maladaptive behavioral index score, along with the date of evaluation, ensuring the ICAP summary is less than one year old.
4. In the CILA provider and site information section, enter the provider agency name, four-digit DHS number, address, county, and total residential capacity of the CILA site.
5. Indicate the level of CILA support services provided at the site and answer whether night shift staff may sleep. Make sure to answer additional questions regarding the specific type of support services being requested.
6. List all individuals currently living at or moving to the CILA site. Indicate their current funding status by answering the relevant yes/no questions.
7. Move on to the rate type and residence location prior to CILA placement. Select the appropriate options based on the individual's eligibility and past residence.
8. In the signatures section, ensure the application is signed and dated by both the CILA provider and the ISC agency representative. Check that all required attachments are noted and prepared.
9. Finally, review all information for completeness and accuracy. Once confirmed, you can save your changes, download, print, or share the form as needed.

Complete documents online today to ensure timely processing of your application.