Get LISS Request Form 2011

Developmental Disabilities Administration Low Intensity Support Services LISS Request Form APPLICANT INFORMATION Last Name First Middle Marital Status circle one Single Married Div Address City State Sep Widow Zip Code Sex M / F County Cell Phone Day/Work Home Date of Birth Age Email Address If applicable Social Security Medical Assistance If none date of application For applicant over the age of 18 Demographic Information - for internal use only - does not apply to eligibility Individual s Annual Income optional Primary Disability Household Annual Income optional Race circle one Black/African American Hispanic White/Caucasian Asian American Indian/Alaska Native American Pacific Other What is the relationship of the person completing this form to the applicant Self Parent Spouse Guardian Resource/Service Coordinator School Counselor Other If not self please note name of person completing this form Phone Please check all programs and services the applicant is currently receiving services or resources from DDA Resource/Service Coordination Day/Supported Employment CSLA Community Pathways or New Directions OTHERS Special Education Division of Rehabilitation Services DORS Food Bank Transportation MA Waivers Autism REM Rare Expensive Case Management Model MA Personal Care Traumatic Brain Injury In-Home Aid Services DSS Living at Home Attendant Care Program Older Adults Medical Day Care RTC Residential Treatment Center Social Services Energy Assistance MEAP Housing Other Resource/Service Coordinator/Case Manager Name Email SERVICE/ITEM REQUEST Eligible Support/ Activity/ Item Name Address Telephone of Provider of Support/Activity/Item Cost of Dates of 660. 00 Documentation of cost This must be included June 20 August 25 To whom the payment is made EXAMPLE -Summer Camp ABC CAMP 123 Any Way Anywhere MD 12345 410-222-2222 FOR RESPITE REQUEST ONLY NAME OF PROVIDER DAILY RATE AMOUNT OF DAYS YES Where else has funding been sought and the status i*e* application pending denied or the amount funded Applicant s Contribution if any APPLICANTS ARE REQUIRED TO SUBMIT APPROPRIATE DOCUMENTATION INCLUDING A COPY OF THE SOCIAL SECURITY CARD PROOF OF RESIDENCY AND PROOF OF DEVELOPMENTAL DISABILITY IN ORDER FOR ELIGIBILTY TO BE CONSIDERED. Applicant Declaration By signing this application I hereby attest that the information provided to process the Low Intensity Support Services LISS funding request is accurate to the best of my knowledge. I understand LISS funding is not an entitlement program and receipt of LISS funds is on a first come first serve basis. LISS funding is contingent upon DDA s LISS eligibility criteria verification of the above information and funding availability. Signature of Applicant Name Print Person designated to receive correspondence Form Effective 7/1/2011 Date. 00 Documentation of cost This must be included June 20 August 25 To whom the payment is made EXAMPLE -Summer Camp ABC CAMP 123 Any Way Anywhere MD 12345 410-222-2222 FOR RESPITE REQUEST ONLY NAME OF PROVIDER DAILY RATE AMOUNT OF DAYS YES Where else has funding been sought and the status i*e* application pending denied or the amount funded Applicant s Contribution if any APPLICANTS ARE REQUIRED TO SUBMIT APPROPRIATE DOCUMENTATION INCLUDING A COPY OF THE SOCIAL SECURITY CARD PROOF OF RESIDENCY AND PROOF OF DEVELOPMENTAL DISABILITY IN ORDER FOR ELIGIBILTY TO BE CONSIDERED. Applicant Declaration By signing this application I hereby attest that the information provided to process the Low Intensity Support Services LISS funding request is accurate to the best of my knowledge. .