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Liss request form 2011-2026
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- Click ‘Get Form’ to open the LISS Request Form 2011 in the editor.
- Begin by filling out the Applicant Information section. Enter your last name, first name, middle name, marital status, address, city, state, zip code, sex, county, and contact numbers. Ensure all details are accurate.
- Provide your date of birth and age. If applicable, include your email address and Social Security number. For applicants over 18 without a Medical Assistance number, indicate the date of application.
- Complete the Demographic Information section for internal use only. This includes optional fields like annual income and primary disability.
- Indicate your relationship to the applicant and provide contact information if you are not the applicant.
- Check all programs and services currently being received by the applicant from DDA or other sources.
- In the Service/Item Request section, list eligible supports or items along with provider details and associated costs. Include documentation of costs as required.
- Complete any additional sections regarding funding status and contributions before signing the application to attest to its accuracy.
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