Dss-5027-2025

1. Click ‘Get Form’ to open the dss-5027 in the editor.
2. Begin by filling out Section A, Client Identifying Information. Enter the CLIENT ID, CLIENT NAME (last and first), DATE OF BIRTH, and CLIENT SOCIAL SECURITY NO. Ensure accuracy as this information is crucial for identification.
3. Proceed to Section B, Service Plan. Here, indicate SERVICES REQUESTED and select the DECISION. Fill in the SERVICE CODE and DATE REQUESTED. If applicable, provide the DATE TERMINATED and REASON for termination.
4. In Section C, Notice of Action Taken, review the services marked 'Yes' or 'No'. This section outlines your eligibility for services and any fees associated with them.
5. Complete Section E, Income Information by detailing INCOME TYPE and INCOME AMOUNT. This helps assess your financial eligibility for services.
6. Finally, sign in Section G to confirm that all provided information is correct. Include the date of signature and witness signature if required.

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