Apd - Application For Services Form Page 3
ADVERTISEMENT
1
2
3
4
5
6Application for Services
8.
Citizenship Verification (must check one)
:
(to be filled out by APD Staff):
To receive services from APD, the applicant and parent or legal guardian (if applicable) must be domiciled in Florida, and the applicant must be
a U.S. citizen or resident alien
Is the applicant a U.S. Citizen?
YES
NO
Place of Birth:
United States (What State?) ____________________
Other (Name of Country)________________________
If not a US citizen, must provide USCIS alien status and number (also please fill out page 6 of this application):
Permanent Resident
Other:________________________ USCIS #:_____________________________________________
Type of documentation provided for proof of citizen or alien status:
US Birth Certificate
US Passport
Certificate of Naturalization/Citizenship
Green Card
USCIS Issued Form
9.
Residency:
Is the person requesting services a resident of the state of Florida?
YES
NO
If the applicant is a minor, is the parent or legal guardian domiciled in Florida?
YES
NO
Has the applicant recently relocated to Florida?
YES
NO
If YES, please explain ___________________________________________________________________________________________
Residency Verification (must check one)
(to be filled out by APD Staff):
FL Driver’s License/ID Card;
Voter Registration Card;
FL Court Filed Declaration of Domicile;
Utility Bill;
Mortgage or Lease
Agreement;
Employment/School Record
10. Eligibility Assessments:
Do you agree to participate in assessment(s) that may be needed to find out if you are eligible for services provided by APD?
YES
NO
Assessment Needed
(to be filled out by APD Staff):
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________
11. APD Eligibility Determination
12. Collateral/Supporting Information or Source of Information
(to be filled out by APD Staff):
About Disability
(to be filled out by APD Staff):
Eligible for APD: _____________ Date: ___/___/_____
(IQ scores, medical records, school records, etc.)
Eligibility Category: _____________________________________
Not eligible Date: ___/___/_____
Reason: ____________________________________
13. Waiver Eligibility Determination
14. ICF Eligibility Determination
(to be filled out by APD Staff):
(to be filled out by APD Staff):
Eligible for Medicaid Waiver: Date: ___/___/_____
Eligible for ICF: Date: ___/___/_____
Not eligible Date: ___/___/_____
Not eligible Date: ___/___/_____
Reason: ____________________________________
Reason: ____________________________________
Updated January 21, 2016
3
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business