Form 10-007 - Application For Services Form

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Application for Services
Grey areas are for completion by APD office staff only.
Area Office: _____
Phone #: ____________________________
Name of APD Staff Person:
Date of Application:
1.
Services Requested
I am requesting participation in either the Family and Supported
I am requesting the following services from the Agency for Persons
Living or the Developmental Disabilities Home and Community-
with Disabilities:
Based Services Waivers.  Yes
 No
OR
II am requesting to be served in an intermediate care facility.
 Yes
 No
2.
Person for Whom Support and Services Are Requested
3.
Person Assisting Applicant
Name:________________________________________________
Name:__________________________________________
(Last)
(first)
(MI)
(Suffix)
(Last)
(first)
(MI)
SS#: *________________________________________________
Relationship to Applicant: __________________________
Medicaid #: ___________________________________________
Address: _______________________________________
Address:______________________________________________
_______________________________________________
_____________________________________________________
Phone #: _______________________________________
Phone #:______________________________________________
Alternate Phone #: _______________________________
Alternate Phone #: _____________________________________
Email: _________________________________________
Email: _______________________________________________
Is this person an active Community Based Care (CBC)/Child Welfare
services recipient?
YES
NO
DOB: ________________________________ Sex: _______
If Yes:
Is he or she receiving out-of- home (foster care) services?
Legal Status:___________________________________________
YES
NO
(see instructions)
Is he or she receiving in-home (protective supervision) services?
Preferred Language of Applicant/Guardian: __________________
YES
NO
4.
Residency: Please check all that apply:
5.
Eligibility Assessments:
 Florida Resident
 US Citizen
 Resident Alien
I agree to participate in assessment(s) that may be needed to find out
if I am eligible for services provided by APD.
Place of Birth: ________________________________________
 Yes  No
(state)
country)
Assessments Needed: ____________________________
To receive services from APD, the applicant must be domiciled in
Florida, and be a U.S. citizen or resident alien.
_______________________________________________
_______________________________________________
Type of documentation provided to show residency and ID (birth
certificate, Green Card, driver’s license, school photo ID, etc.):
_______________________________________________
_____________________________________________________
__________________________________
Page 1
FORM TITLE: APPLICATION FOR SERVICES, RULE 65G-4.016
FORM NUMBER: 10-007
YEAR: 2007

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