Ill. Admin. Code tit. 59, pt. 117, subpt. C, app A, ILLUSTRATION B

Current through Register Vol. 49, No. 2, January 10, 2025

DMHDD - 1236, Family Assistance Program Application

Illinois Department of Human Services

THE PRELIMINARY FAMILY ASSISTANCE PROGRAM APPLICATION

A new program for adults with a severe developmental disability or a severe mental illness. For more information call the Department's toll free number 1-800-843-6154.

Please read the brochure before completing items 1-10 below, print or type clearly and sign the application:

1. Child's name: ___________________________________________________

2. Sex:MaleFemale

3. Child's raceWhiteBlackHispanicOther

4. I believe my child has:severe autism;severe emotional disturbance;

severe or profound mental retardation;severe and multiple impairments.

5. Child's birthdate: ___/ ___ /___

6. Child's social security number (if available): _______________________________

7. Parent's/guardian's Name: ____________________________________________

Street address: ________________________________________________

_________________________________________________________________

CityStateZipCounty

8. Parent's/guardian's telephone number: __________________________________

9. Family taxable income:under $50,000over $50,000

10.

a. My child lives in the family home now:YesNo

b. My child lives outside the family home now, but if I am chosen to participate in this program I plan to bring my child back into the family home:

YesNo

11. Is this a foster child:YesNo

I declare that the information above is true and I understand that if I am chosen this information will be confirmed by the Illinois Department of Human Services through an assessment to assure my eligibility to participate in the Home-Based Support Services Program.

___________________ ___________________

Parent/guardiansignature Date

Ill. Admin. Code tit. 59, pt. 117, subpt. C, app A, ILLUSTRATION B