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Liss request form 2011

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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 RESIDENC ...

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