A Preliminary Application forms

Section 117.APPENDIX A   Preliminary Application forms Section 117.ILLUSTRATION A   DMHDD-1235, Home-Based Support Services Program Application Illinois Department of Human Services THE PRELIMINARY FAMILY ASSISTANCE PROGRAM APPLICATION A new program for adults with a severe developmental disability or a severe mental illness.  For more information call the Department's toll free number 1-800-843-6154. Please read the brochure before completing items 1-10 below, print or type clearly and sign the application: 1. Applicant's name: 2. Sex: Male Female 3. Applicant's race White Black Hispanic Other 4. Applicant is believed to have: severe autism; severe mental illness; severe or profound mental retardation; severe and multiple impairments. 5. Applicant's birthdate: / / 6. Applicant's social security number: 7. Applicant's address: Street City State Zip County 8. Applicant's telephone number: Area code Number 9. a. The applicant lives in his/her own home/apartment now: Yes No b. The applicant lives outside his/her home now but is a planning to move to his/her own home/apartment if chosen to participate in this program: Yes No 10. Applicant is enrolled in a special education program Yes No I declare that the information above is true and I understand that if I am chosen this information will be confirmed by the Illinois Department of Human Services through an assessment to assure my eligibility to participate in the Home-Based Support Services Program. Applicant's or guardian signature Date Guardian's name Guardian's telephone number: Guardian's address: Section 117.APPENDIX A   Preliminary Application forms Section 117.ILLUSTRATION B   DMHDD – 1236, Family Assistance Program Application Illinois Department of Human Services THE PRELIMINARY FAMILY ASSISTANCE PROGRAM APPLICATION A new program for adults with a severe developmental disability or a severe mental illness.  For more information call the Department's toll free number 1-800-843-6154. Please read the brochure before completing items 1-10 below, print or type clearly and sign the application: 1. Child's name: 2. Sex: Male Female 3. Child's race White Black Hispanic Other 4. I believe my child has: severe autism; severe emotional disturbance; severe or profound mental retardation; severe and multiple impairments. 5. Child's birthdate: / / 6. Child's social security number (if available): 7. Parent's/guardian's Name: Street address: City State Zip County 8. Parent's/guardian's telephone number: 9. Family taxable income: under $50,000 over $50,000 10. a. My child lives in the family home now: Yes No b. My child lives outside the family home now, but if I am chosen to participate in this program I plan to bring my child back into the family home: Yes No 11. Is this a foster child: Yes No I declare that the information above is true and I understand that if I am chosen this information will be confirmed by the Illinois Department of Human Services through an assessment to assure my eligibility to participate in the Home-Based Support Services Program. Parent/guardian signature Date