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Illinois
Department of Human Services
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THE
PRELIMINARY FAMILY ASSISTANCE PROGRAM APPLICATION
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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.
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Please read the brochure
before completing items 1-10 below, print or type clearly and sign the
application:
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1.
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Applicant's name:
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2.
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Sex:
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Male
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Female
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3.
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Applicant's race
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White
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Black
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Hispanic
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Other
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4.
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Applicant is believed to have:
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severe autism;
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severe mental illness;
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severe or
profound mental retardation;
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severe and multiple
impairments.
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5.
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Applicant's birthdate:
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/
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/
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6.
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Applicant's
social security number:
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7.
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Applicant's
address:
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Street
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City
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State
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Zip
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County
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8.
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Applicant's
telephone number:
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Area code
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Number
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9.
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a.
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The applicant lives in his/her
own home/apartment now:
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Yes
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No
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b.
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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:
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Yes
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No
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10.
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Applicant is enrolled in a
special education program
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Yes
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No
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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.
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Applicant's or guardian
signature
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Date
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Guardian's name
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Guardian's telephone number:
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Guardian's address:
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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:
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1.
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Child's name:
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2.
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Sex:
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Male
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Female
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3.
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Child's race
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White
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Black
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Hispanic
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Other
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4.
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I believe my child has:
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severe autism;
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severe emotional disturbance;
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severe or
profound mental retardation;
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severe and multiple
impairments.
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5.
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Child's birthdate:
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/
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/
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6.
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Child's
social security number (if available):
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7.
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Parent's/guardian's
Name:
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Street
address:
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City
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State
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Zip
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County
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8.
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Parent's/guardian's
telephone number:
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9.
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Family taxable income:
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under
$50,000
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over
$50,000
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10.
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a.
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My child lives in the family
home now:
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Yes
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No
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b.
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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:
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Yes
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No
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11.
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Is this a foster child:
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Yes
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No
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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.
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Parent/guardian
signature
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Date
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