Follow the steps to fill out the Liss Services Eligibility Application effectively.

1. Press the ‘Get Form’ button to access the Liss Services Eligibility Application and open it in your preferred editor.
2. Begin by filling out the 'Applicant Information' section. This includes the last name, first name, middle name, social security number, date of birth, and telephone number of the applicant, who is the person with a disability.
3. In the 'Service Information' section, complete all fields without indicating 'see attached.' Start with the service/item request, providing a clear description of the service needed.
4. Enter the name and address of the vendor or service provider in the next field, followed by the licensed professional’s name and license number if applicable.
5. Provide the vendor or service provider's telephone number. This allows for verification and communication regarding the service request.
6. Indicate the total amount requested for the service/item. This figure is crucial for determining funding eligibility.
7. Specify the dates of service, ensuring they fall between July 1 and June 30, with the exception of camps, which are valid through August 31.
8. Next, fill in the daily or hourly rate and the total amount of days or hours needed for services like respite and support.
9. State your reasons for requesting the above service/item. Provide clear and informative justifications, as these are necessary for processing your application.
10. Sign the application under the 'Applicant Declaration.' This confirms that the information provided is accurate to the best of your knowledge. If an authorized representative is filling out the request for a child, they should sign the application as well.
11. Lastly, include the name, telephone/email, and mailing address of the person designated to receive correspondence, if applicable. This ensures that any communications regarding the application can be directed to the appropriate individual.
12. Once all sections are completed, review your application thoroughly for any errors or omissions. Save your changes, then download, print, or share your completed form as necessary.

Contact your local office to complete the Liss Services Eligibility Application online.