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Low Intensity Support Services (Liss) Request Form - Developmental Disabilities Administration - 2014

For LISS Purposes only

Developmental Disabilities Administration

DATE STAMP:

Low Intensity Support Services (LISS)

Request Form

SECTION 1

PROGRAM INFORMATION

1. LISS are grants up to $2000 to assist families in providing for the needs of a child or an adult with a developmental disability living in the home, or support

an adult with developmental disabilities living in the community.

2. Applicants must submit the required documentation including a copy of their Social Security card, proof of developmental disability, and proof of residency

for eligibility consideration.

3. Eligible services and items include but are not limited to following:

ADA compliant household appliances

Camps

Housing Assistance

Specialized Equipment

Adaptive Clothing

Childcare

Personal Care

Therapies

Adaptive Equipment

Conference admission

Recreation

Transportation costs

Adaptive Furniture

Health insurance co-pays, deductibles, co-insurance

Recreational Memberships

Vehicle Modifications

Advocacy Training

Health Services & Items

Respite

Assistive Technology

Housing Adaptations/Accessible Housing

Sensory items & Services

4. LISS request can be submitted July 1 through July 31 and January 1 through January 31 of each year.

5. Applicants must submit their request to the LISS provider serving their particular county. Please see the DDA/LISS website for provider information:

SECTION 2

APPLICANT INFORMATION

Last Name:

First:

Middle

Street Address:

City:

E-mail address:

Sex: M / F

Date of Birth:

County:

Zip Code: