Appendix 525-05-60

Application for Service, SFN 1047 525-05-60-05

(Revised 1/1/07 ML #3057)

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Purpose:  For individuals to formally request Home and Community Based Services.

Prior to conducting a comprehensive assessment, an applicant (or legal representative) must complete the application form.  

• Date – date of application;
• Agency – County Social Service Board of applicant’s physical county;
• Name – print the name of the applicant (one SFN 1047 per applicant);
• I apply for services to assist me with – the applicant indicates what services or programs for which the applicant is requesting assistance;
• FOR YOUR INFORMATION – applicant must read this section prior to signing;
  • The applicant must check to acknowledge the receipt of the "Your Rights and Responsibilities" brochure.

• Signature section – the applicant and/or the legal representative must sign and date the application form.